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A    TEXT-BOOK    ON    GONORRHEA 
AND  ITS  COMPLICATIONS 


A  TEXT-BOOK 

ON 

GONORRHEA 

AND     ITS     COMPLICATIONS 


BY 


DR.  GEORGES  LUYS 

I-ATE    ASSISTANT   TO   THE   UROLOGICAI.    CLINIQUE,    hOpITAL    LARIHOISlfeRE,    PARIS 
PRIZEMAN   OF    THE    FACULT^    DE   M^DECINE,    PARIS 


TRANSLATED  AND  EDITED 

EY 

ARTHUR  FOERSTER,  M.RC.S.,  L.R.C.P.   (Lond.) 

LATE   RESIDENT    MEDICAL    OFFICER,    LONDON    LOCK    HOSPITAL 


WITH   200   ILLUSTRATIONS  AND  3   COLOURED  PLATES 


NEW    YORK 
WILLIAM    WOOD    &    COMPANY 

MDCCCCXIII 


Q. 


AUTHOR'S   PREFACE 

Gonorrhea  is  one  of  the  scourges  of  humanity  which  have  received  so  far 
but  shght  attention  from  the  general  pubhc.  Whilst  the  dangers  of  syphiHs 
are  a  matter  of  common  knowledge,  gonorrhea  is  often  made  hght  of,  and 
yet  this  disease  is  more  common,  and  causes  endless  misery  amongst  the 
innocent.  Its  sequelae,  which,  unfortunately,  are  insufficiently  known,  are 
just  as  serious,  both  from  the  social  and  from  the  individual  point  of  view, 
as  those  of  syphihs,  although  they  are  less  tragic  in  appearance. 

Gonorrhea  is  no  benign  disease  which  calls  for  jocular  comment;  it  is 
a  serious  illness  which  may  terminate  fatally.  Badly  treated  or  insuffi- 
ciently cured,  it  produces  lesions  in  the  male  which  embitter  his  best  years 
or  his  old  age;  and  in  both  sexes  it  gives  rise  to  systemic  complications, 
of  which  those  involving  the  joints  and  the  heart  are  the  most  important. 

In  fact,  the  gonococcus,  the  usual  cause  of  the  malady,  does  not  always 
remain  within  the  mucous  membrane  of  the  urethra;  it  enters  the  blood- 
stream more  frequently  than  is  generally  believed,  and  thus  sets  up  a 
generalized  septicemia  and  fatal  cardiac  lesions,  which  are,  unfortunately, 
by  no  means  as  rare  as  one  might  expect. 

When  a  man  acquires  an  attack  of  gonorrhea,  sensations  of  pain  and 
of  burning  in  his  urethra  soon  acquaint  him  with  his  misfortune;  but  once 
the  acute  stage  has  passed  off,  he  undervalues  the  importance  of  his 
"  accident."  He  rapidly  forgets  that  he  is  contagious,  neglects  his  treat- 
ment or  postpones  it,  and  finally  fails  to  be  cured. 

Careless,  ignorant,  or  guilty,  he  enters  upon  wedlock,  and  gives  his 
young  spouse  in  exchange  for  her  virginity  a  poison  which  may  cripple  or 
kill  her.  The  great  danger  at  this  moment  is  the  absence  of  acute  symptoms, 
and  thus  the  unfortunate  wife  has  no  suspicion  of  the  true  nature  of  her 
illness — an  illness  which  ruins  so  many  young  women  between  eighteen 
and  twenty.  It  is  pitiful  to  see  the  pale  faces,  the  anxious  and  worn  looks, 
the  hollow  eyes  of  these  poor  young  women  who  suffer  permanently  from 
internal  pains,  until  they  submit  to  a  surgical  operation  which  gives  them 
the  desired  relief,  but  also  condemns  them  to  complete  steriHty. 

Such  are  the  disasters  brought  on  by  gonorrhea.  Its  victims  amongst 
both  sexes  are  so  numerous  that  it  must  be  the  duty  of  medical  men  to 
point  out  its  dangers  to  pubHc  resentment.    It  is  one  of  the  most  frequent 


vi  AUTHOR'S  PREFACE 

causes  of  depopulation,  and  it  is  responsible  for  the  "  wrecking "  of  so 
many  men,  and  for  the  sterility  of  so  many  women. 

Owing  to  the  slow,  but  sure  havoc  which  it  causes  in  the  individual, 
and  to  Society,  gonorrhea  deserves  the  fullest  attention  of  medical  men  and 
of  pubhc  bodies.  To  aid  and  to  guide  them  in  their  campaign  against  this 
plague  is  the  object  of  this  book. 

Our  therapy  is  nowadays  so  perfect  that  it  is  not  permissible  for  a 
medical  man  to  allow  a  case  of  gonorrheal  urethritis  to  go  on  without  curing 
it.  Modern  science  has  made  such  conquests  that  one  can  say  without 
exaggerating  that  there  is  no  inflammation  of  the  urethra  which  cannot  be 
cured  completely  by  appropriate  treatment.  But  it  should  not  be  for- 
gotten that  this  result  is  only  obtained  by  means  of  prolonged  and  pains- 
taking observations,  and  that  urethroscopy  alone  enables  us  to  diagnose 
the  local  lesions  "with  accuracy,  and  to  apply  the  sovereign  remedy  correctly. 
Without  the  control  of  his  eye,  it  is  impossible  for  the  medical  man  to 
select  the  best  and  the  most  efficacious  treatment. 

It  does  not  follow  from  the  fact  that  urethroscopy  is  a  wonderful  and 
indispensable  means  of  diagnosis  in  expert  hands  that  it  is  a  universal 
panacea  for  inflamed  urethrae.  The  truth  is  far  from  this,  and  hence  it  is 
necessary  to  study  the  treatment  of  urethral  inflammation  in  all  its  details. 

On  the  whole,  the  therapeutic  measures  recommended  in  this  book  have 
little  in  common  with  the  routine  treatment  of  former  days. 

An  experience  of  twelve  years  devoted  to  the  study  of  these  interesting 
diseases  has  convinced  me  of  the  absolute  efficiency  of  certain  remedies, 
and  of  their  superiority  over  others  which  fortmiately  have  become  obsolete 
nowadays.  I  have  therefore  avoided  a  tiresome  enumeration  of  the  old 
methods  which  prolonged  the  urethritis  instead  of  curing  it,  and  given  a 
very  full  description  of  our  modern  accurate  therapeutic  measures  which 
lead  to  a  certain  cure. 

This  book  contains  twelve  chapters. 

The  history  of  gonorrhea  I  considered  of  interest.  It  shows  the  evolu- 
tion of  our  knowledge  of  the  etiology  and  of  the  therapy  of  the  disease; 
how  gradually  in  the  course  of  centuries  a  state  of  chaos  and  darkness  was 
replaced  by  accuracy  and  clearness. 

The  following  chapters  deal  with  the  etiology  of  gonorrhea,  and  give  a  full 
description  of  the  gonococcus,  the  usual  cause  of  the  malady.  They  also 
point  out  its  dangers,  and  refer  to  the  social  struggle  against  gonorrhea,  and 
to  certain  legal  questions  connected  with  it. 

As  the  gonococcus  is  not  the  only  micro-organism  capable  of  producing 
an  inflammation  of  the  urethra,  a  further  chapter  is  devoted  to  these  non- 
gonococcal urethrites. 

The  basis  of  all  rational  treatment  is  the  pathological  finding,  and  thus 
a  special  chapter  deals  with  the  pathology  of  gonorrhea. 


AUTHOR'S  PREFACE  vii 

In  the  next  chapter  the  chnical  picture  and  the  symptomatology  are 
described. 

The  diagnosis  of  urethral  inflammation  has  received  special  attention, 
as  it  guides  the  treatment,  and  as  the  success  of  the  latter  depends  on  the 
accm'acy  and  completeness  of  the  former. 

The  following  chapter  gives  a  full  description  of  urethroscopy,  and 
completes  the  previous  chapter.  Without  this  powerful  means  of  diagnosis, 
the  locahzations  of  chronic  urethritis  cannot  be  made  out,  and  therefore 
remain  untreated. 

The  numerous  comphcations  of  gonorrhea  are  then  reviewed,  a  special 
chapter  being  devoted  to  gonorrhea  in  women  and  children. 

The  later  two  chapters,  which  are  the  most  important  ones,  give  a  full 
description  of  the  treatment  of  acute  and  of  chronic  gonorrhea.  They 
contain  the  methods  which  have  stood  the  tests,  and  lead  to  a  certain  cure 
if  properly  apphed. 

This  book  has  been  illustrated  with  special  care,  most  of  the  figures 
being  original.  They  are  intended  to  render  the  reader  famihar  with  the 
various  therapeutic  interventions,  and  to  give  him  the  impression  that  he 
is  operating  himself. 

Lastly,  I  have  to  discharge  the  pleasant  duty  of  thanldng  my  pubhshers, 
Messrs.  0.  Doin  et  Fils,  for  the  admirable  way  in  which  they  have  published 
this  book. 

GEOEGES  LUTS. 


TRANSLATOR'S    PREFACE 

In  recent  years  a  greater  interest  has  been  taken  in  venereal  diseases,  and 
it  would  seem  as  if  the  days  in  which  it  was  permissible  to  treat  these 
maladies  with  contempt  and  in  a  careless  manner  belonged  to  the  past. 
It  is  being  more  and  more  reahzed  that  the  fact  of  contracting  a  venereal 
disease  is  purely  and  simply  a  misfortune,  and  in  itself  no  proof  of  immor- 
ality, calling  for  disapproval  and  punishment.  It  is  gratifying  to  find 
leading  journals,  like  the  Times,  devoting  their  columns  occasionally  to 
■  important  advances  in  venereology. 

Syphilis  has  been  a  good  field  for  medical  research  in  recent  years. 
Valuable  discoveries  have  followed  each  other  in  rapid  succession,  and  thus 
the  attention  of  the  pubhc  and  of  the  medical  profession  has  been  concen- 
trated on  this  malady,  which  in  the  past  hall-marked  the  majority  of  its 
victims,  and  could  not  fail  to  impress  even  the  most  hard-hearted.  Much 
has  been  done  of  late  for  the  syphihtics,  and  an  enormous  literature  has 
sprung  which,  it  is  to  be  feared,  is  already  too  extensive. 

The  other  venereal  diseases  have  thus  dropped  into  the  background, 
and  it  seems  timely  to  bring  their  principal  member,  gonorrhea,  to  the  front 
again.  Its  frequency  and  its  dangers,  which  are  dealt  with  in  this  work, 
would  be  in  themselves  an  ample  justification.  There  can  be  no  doubt 
that  its  victims  deserve  our  fullest  sympathy,  and  that  they  require  the 
same  care  and  attention  as  patients  suffering  from  other  diseases,  were  it 
only  for  the  sake  of  their  surroundings  and  of  their  offspring.  As  far  as 
"  guilt "  and  "  sin  "  are  concerned,  it  would  be  well  to  cast  off  the  cloak 
of  hypocrisy  and  to  adopt  charitable  feehngs.  The  cirrhotic  who  has 
dehberately  ruined  his  health,  to  quote  an  example,  and  an  enormous 
percentage  of  those  who  meet  with  accidents  or  injuries,  are  just  as  "  guilty," 
and  their  lesions  are  to  the  same  extent  "  self-inflicted  "  as  any  venereal 
disease. 

The  victims  of  their  passions  suffer  enough  as  it  is.  The  long  duration 
of  their  illness,  the  restrictions  they  have  to  impose  upon  themselves,  and 
the  knowledge  of  being  "  unclean,"  as  Moses  termed  it,  and  of  being  put 
out  of  action,  lead  to  endless  mental  suffering,  which  often  inspires  one  with 
pity.     To  inflict  upon  these  sufferers  reHgious  treatment,  as  some  seem  to 

ix  h 


X  TRANSLATOR'S  PREFACE 

think  fit,  in  preference  to  a  proper  medical  tkerapy,  verges  on  barbarism, 
and  is  not  in  harmony  with  our  times. 

In  the  case  of  gonorrhea  in  particular,  our  medico-surgical  measures 
are  excellent  and  practically  guarantee  a  cure.  They  appear,  however,  to 
be  inadequately  known,  and  even  amongst  medical  men  a  certain  uncer- 
tainty appears  to  exist,  as  far  as  the  treatment  of  gonorrhea  is  concerned. 
This  state  of  afTairs  is  not  astonishing,  considering  that  for  a  number  of 
years  no  book  has  been  pubhshed  in  the  Enghsh  language  on  this  subject. 
It  is  true  that  several  valuable  works  on  urinary  diseases  have  been  written 
of  late,  and  that  they  allude  to  gonorrhea.  But  these  references  are  scanty, 
suitable,  perhaps,  for  experts  who  do  not  require  them.  Those  who  are 
less  famihar  with  this  malady  and  seek  detailed  information  will  find  little 
assistance  in  consulting  these  books.  There  is  thus  a  gap  in  our  hterature, 
and  I  have  attempted  to  fill  it  by  this  translation  of  a  treatise  which  has 
already  made  its  reputation  and  contains  all  the  information  one  could 
desire. 

Its  author,  Dr.  Georges  Luys,  is  a  recognized  authority,  and  so  well 
known  by  his  numerous  writings  and  inventions,  that  all  his  communications 
deserve  attention.  His  "  Traite  de  la  Blennorragie,"  of  which  the  present 
volume  is  a  translation,  deals  exclusively  with  that  malady,  and  is  the  most 
complete  book  so  far  pubhshed  on  this  subject.  The  first  edition  appeared 
only  in  1912.  Within  a  year  a  second  edition  became  necessary  ;  an 
abridged  Spanish  translation  has  already  been  pubhshed,  and  a  Russian 
version  is  about  to  appear. 

The  text  of  the  present  Enghsh  edition  embodies  all  the  additions  and 
corrections  of  the  second  French  edition,  although  it  differs  here  and  there 
from  the  latter.  We  have  also  been  able  to  insert  all  the  important  new 
figures,  owing  to  the  efforts  of  my  pubHshers,  Messrs.  Bailhere,  Tindall  and 
Cox,  to  whom  my  thanks  are  due  for  the  care  which  they  have  bestowed 
upon  this  work.  On  the  other  hand,  we  have  omitted  some  of  those  figures 
which  appear  twice  in  the  original,  and  a  few  of  minor  interest. 

Some  of  our  readers  will  regret  that  the  references  to  vaccine  treatment 
are  brief;  but  as  neither  Dr.  Luys  nor  myseK  are  greatly  impressed  by  its 
achievements,  we  decided  not  to  enlarge  the  paragraph  relating  to  it. 

It  has  been  the  aim  to  lay  stress  upon  such  methods  only  which  are 
reliable,  and  which  should  be  employed  by  those  whose  lot  it  is  to  cure 
gonorrhea  and  to  alleviate  the  terrible  martyrdom  of  the  sexual  organs. 


A.  FOERSTER. 


London,  W. 
July,  1913. 


CONTENTS 

CHAPTER  PAGE 

I.  THE  HISTORY  OF  GONORRHEA          -            -             -  -  -  1 

II.  THE  DANGERS  OF  GONORRHEA       -              -            -  -  -  12 

The  Social  Struggle  against  Gonoskhea          -            -  -  -  17 

The  Legal  Aspect  of  Gonorrhea            -            -            -  -  -  18 

III.  THE  ETIOLOGY  OF  GONORRHEA        -            -            -  -  -  21 

The  Gonococctjs     -            -            -            -            -            -  -  -  21 

Frequency           --------  21 

Ways  in  which  the  Contamination  is  brought  about-  -  -  21 

Contamination  through  Inert  Objects  -             -             -  -  -  24 

Effect  of  Age— Gonorrhea,!  Vulvitis  in  Little  Girls     -  -  -  25 

Inllueiace  of  Fever         -             -             -             -             -  -  -  25 

Morphology  of  the  Gonoooccus  -            -            -            -  -  -  26 

Shape,  Grouping,  Movements   -             -             •             -  -  -  26 

Staining  Properties        -             -             -             -             -  -  -  27 

Technique  of  Searcihng  for  Gonococci             -            -  -  -  27 

Examination  of  the  Discharge  and  of  the  Filaments  -  -  27 

Staining:  Kiihne's  Method;  NicoUe's  Method               -  -  -  28 

Double  Staining              -             -             -             -             -  -  -  29 

Gram's  Method               ---.--  -  29 

Staining  of  Sections       -  ■            -             -             -             -  -  -  30 

Examination  under  the  Microscope       -            -            -  -  -  30 

Cultivation  of  the  Gonococcus              -            -            -  -  -  31 

Coagulated  Human  Blood-Serum          -             -             -  -  -  31 

Serum-Agar        -             -             -             ^             -             -  -  -  31 

Ascites -Agar       -             -             -             -             -             -  -  -  31 

Ascites  Broth     --------  31 

Coagulated  Rabbit  Serum         -             -             -             -  -  -  31 

Pig's  Serum;  Wassermann's  Medium    -             -             -  -  -  31 

Blood-Agar         - 32 

Henry  Heiman's  Medium          -             -             -             -  -  "  -  32 

Yolk  of  Egg  Agar 32 

Inoculation             ..-.----  33 

The  Toxin  of  the  Gonococcus    -            -            -            -  -  -  33 

Biology  of  the  Gonococcus         -            -            -            -  -  -  -  34 

Relationship  between  Gonococcus  and  Meningococcus  -  -  34 

Localization  op  the  Gonococcus  in  the  Human  Body  -  -  34 

Gonococcal  Septicemia     -            -            -            -            -  -  -  36 

xi 


xii  CONTENTS 

CHAPTER  PAGE 

IV.  INFLAMMATIONS  OF  THE  URETHRA  DUE  TO  OTHER  CAUSES 

THAN  THE  GONOCOCCUS 39 

Inflammations  of  the  Urethra  due  to  Common  Micro -Organisms  -  39 

Primary  Urethritis  of  Bacterial  Origin             -             -  -  -  39 

Secondary  Urethritis  of  Bacterial  Origin          -             -  -  -  40 

So-called  "Aseptic"  Inflammations  of  the  Urethra  -  -  43 

Inflammations  of  the  Urethra  due  to  Chemicals      -  -  -  45 

Inflammations  of  the  Urethra  due  to  a  Special  Diathesis  -  46 

Inflammations  of  the  Urethra  due  to  Toxins            -  -  -  46 

Inflammations  of  the  Urethra  of  Traumatic  Origin  -  -  47 

V.  THE  ANATOMY  OF  THE  URETHRA,  AND  THE  PATHOLOGY  OF 

GONORRHEA      -                         -            -            -            -  -  -  48 

The  Anatomy  of  the  Urethra           -            -            -            -  -  -  48 

I.  The  Male  Urethra        -            -            -            -            -  -  -  48 

Course  and  Different  Parts            -            -.           -  -  -  49 

Anterior  and  Posterior  Urethra  -            -            -  -  -  49 

Lumen  of  the  Urethra          -            -            -            -  -  -  49 

Length  of  the  Urethra        -            -            -            -  -  -  53 

Outer  Aspect  and  Relations           -            -            -  -  -  63 

1 .  Prostatic  Portion            -             -             -             -  -  -  53 

2.  Membranous  Portion      -             -             -             -  -  -  54 

3.  Spongy  Portion               -             -             -             -  -  -  64 

Inner  Aspect               -            -            ....  .  -  54 

1.  Prostatic  Portion            ....  -  64 

2.  Membranous  Portion      -             -             -             -  -  -  66 

3.  Spongy  Portion               -             -             -             -  -  -  66 

Histology  of  the  Urethra  -            -            -            -  -  -  58 

1.  Muscular  Coat   -             -             -             -             -  -  -  68 

2.  Vascular  Coat    -             -             -             -             -  -  -  68 

3.  Mucous  Coat      -             -             -             -             -  -  -  59 

A.  Structure  of  the  Mucous  Membrane         -  -  -  59 

B.  The  Glandular  Apparatus  of  the  Urethra  -  -  60 

1.  The  Glands  in  the  Anterior  Cavernous  Portion  -  60 

2.  The  Prostate  Gland    -             -             -  -  -  62 

3.  Cowper's  Glands          -             -             -  -  -  63 

II.  The  Female  Urethra               -            -            -            -  -  -  66 

Relations         -            -            -            -            -            -   .  -  -  66 

Inner  Aspect               -            -            -            -            -  -  -  66 

Histology         ---..--.  66 

The  Pathology  of  Gonorrhea           -            -           -            -  -  -  66 

The  Pathology  of  Acute  Urethritis         -            -  -  -  67 

The  Pathology  of  Chronic  Urethritis      ♦            -  -  -  69 

Modifications  of  the  Urethral  Epithelium          -  -  -  70 

Polypi,  Caruncles,  Papillomata,  Condylomata     -  -  -  76 


CONTENTS  xiii 

CHAPTER  FAOB 

VI.  THE  SYMPTOMATOLOGY  OP  ACUTE  GONORRHEA            -            -  78 

AoiTTE  Anterior  Urethritis         -           -           -           -           -           •  78 

1.  Incubation  Period     -            -            -            -            -            -            -  78 

2.  Prodromal  Symptoms           -            -            -            -            -            -  78 

3.  Florid  Stage              ..---..  79 

4.  Period  of  Decline      -            -            -            -            -            -            -  80 

Acute  Posterior  Urethritis        -           -           -           -           -           -  81 

Etiology             --......  81 

Symptoms           -            -            -            -            -            -            -            -  82 

Chronic  Posterior  Urethritis    -           -           -           -           -           -  83 

Symptoms          .--....-  83 

Vn.  THE  DIAGNOSIS  OF  URETHRITIS      -            -            -            -            -  85 

Examination  of  the  Urethral  Secretions       -           -           -           -  85 

1.  Examination  of  the  Discharge  -           -           -           -           -  85 

2.  Examination  of  the  Filaments  in  the  Urine  -            -            -  86 

Thompson's  Method           -            -            -            -            -            -  87 

Kollmann's  Method            -            -            -            -            -            -  88 

Jadassohn-Goldberg  Method          -            -            -            -            -  88 

Krohmeyer's  Method          -            -            -            -            -            -  89 

Lohnsteiti's  Method            -            -            -            -            -            -  89 

Wolbarst's  Method              -            -            -            -            -            -  89 

Practical  Method    -------  90 

Macroscopic  Examination  of  the  Filaments          -            -            -  90 

Microscopic  Examination  of  the  Filaments          -            -            -  91 

Cultivation  of  the  Filaments         -             -             -             -             -  92 

Examination  of  the  Urethra  Proper   -           -           -           -           -  92 

1.  Examination  of  the  Meatus        -            -            -            -            -  92 

2.  Examination  of  the  Prepuce      -            -            -            -            -  94 

3.  Exploratory  Catheterization  of  the  Urethra            -            -  94 

Contra-Indications               -             -             -             -             -             -  94 

Technique                -            -            -            -            -            -            -  95 

Results  obtained  by  Exploratory  Catheterization            -            -  97 

Examination  of  the  Glands  connected  with  the  Urethra  -           -  99 

1.  Exploration  of  Littre's  Glands             .            -            -            .  lOO 

Palpation  of  the  Urethra  ------  100 

2.  Examination  of  Cowper's  Glands           -            -            .            -  102 

3.  Exploration  of  the  Prostate     -----  104 

Rectal  Palpation    -------  104 

Expression  (Milking)          -            -            -            -            -            -  105 

Exploration  by  Means  of  the  Olivary  Bougie     -            -            -  107 

Exploration  by  Means  of  a  Bladder  Sound          -             ■             -  109 

Urethroscopic  Examination            ...             -             -  109 

Cystoscopie  Examination  ------  109 

4.  Examination  of  the  Seminal  Vesicles  -            -            -            -  110 

Palpation  'per  Rectum         -             -             ■■             •             •             -  110 

Expression                --...-.  HO 
Urethroscopic  Examination            -            -            -            -            -111 


xiv  CONTENTS 

CHAPTER  PAGE 

VII.  THE  DIAGNOSIS  OF  URETHRITIS— con^m^e^ 

exajvnnation  of  the  female  urethra   -            -            -            -            -  111 

1.  Cross-Examination             -           -           -           -           -           -  111 

2.  Inspection   -            -            -            -            -            -            -            -  112 

3.  Palpation    -----...  115 

4.  Examination  of  the  Urine  -  -  -  -  -116 

5.  Exploratory  Catheterization     -            -            -            -            -  116 

6.  Urethroscopic  Examination         -            -            -            -            -  116 

VIII.  URETHROSCOPY 117 

The  Importance  of  Urethroscopy          -            -            -            -            -  117 

Its  Importance  for  ascertaining  a  Complete  Cure      -            -            -  119 

The  History  of  Urethroscopy   ------  121 

I.  Urethroscopes  with  External  Illumination    -           -           -  122 

Urethroscopes    with    External    Illumination    attached    to    the 

Urethroscopic  Tube         ------  122 

Urethroscopes  with  External  and  Independent  Illumination      -  126 
Advantages    and    Drawbacks    of    Instruments    with    External 

Illumination         -...-..  128 

II.  Urethroscopes  with  Internal  Ilt.tjmination   -            -            -  131 

Luys's  Urethroscope           .--...  136 

Special  Urethroscopes  for  the  Posterior  Urethra              -            -  139 

Personal  Experiences          .---..  143 

Luys's  Direct  Vision  Cystoscope  -----  144 

The  Supply  of  Electric  Current    -----  145 

The  Technique  of  Urethroscopy           -----  145 

Preparation  of  the  Instruments    -----  148 

Preparation  of  the  Patient            -            -            .            .            .  150 

Operative  Technique          -            -            -            -            -            -  152 

Contra- Indications                -             -             -             -             -             -  155 

On  the  Use  of  Adrenalin  in  Urethroscopy           -             -             -  156 

Urethroscopy  of  the  Urethra  in  Health  and  Disease         -            -  157 

Urethroscopy  of  the  Healthy  Urethra   -            -            -            -  157 

Urethroscopy  of  the  Normal  Anterior  Urethra            -            -  159 

Urethroscopy  of  the  Normal  Posterior  Urethra           -            -  159 

Urethroscopy  of  the  Anterior  Urethra  in  Disease       -            -  162 

Soft  Infiltrations     -             -             -             -             -             -             -  164 

Hard  Infiltrations  -----»-  166 

Lesions  of  the  Lacunae  and  of  the  Glands           -             -             -  168 

Urethroscopy  of  the  Posterior  Urethra  in  Disease     -            -  172 

Urethroscopy  of  the  Female  Urethra      -            -            -            -  180 

Luys's  Direct  Vision  Cystoscope   -----  180 

Technique  of  Direct  Vision  Cystoscopy    -            -             -            -  182 


CONTENTS 


XV 


CHAPTER  PAGE 

IX.  THE  COMPLICATIONS  OF  GONORRHEA        -  -  -  -  187 

Local  Complications  --..__.  137 

Phimosis  and  Paraphimosis   ------  187 

iNGTjrsrAL  Adenitis      -.-.-..  igg 

Inflammation  op  the  Glands  op  the  Anterior  Urethra  -  189 

Littritis  and  Folliculitis     ------  189 

cowpbritis        -.----..  191 

Prostatitis       -  -  -  -  -  -  -  -  194 

Gonorrheal  Inplammation  op  the  Testicle  -  -  -  198 

Medical  Treatment  .--.-.  199 

Surgical  Treatment  ......  2OO 

Sterility  Supervening  upon  Double  Epididymo-Orchitis  -  -  203 

Gonorrheal  Vesicitlitis  (Spermato-Cystitis)  -  -  -  204 

Operative  Treatment  of  Spermato-Cystitis  -  -  -  208 

Vasotomy         -...-..  2O8 

Vesiculotomy  -------  209 

Vesiculectomy  ......  209 

•     A.  Inguinal  Route  -  -  .  -  .  209 

B.  Perineal  Route  .  -  -  -  .  209 

.    C.  Ischio- Rectal  Route    -----  210 

Catheterization  of  the  Ejaculatory  Ducts  -  -  -  210 

Indications       -  -  -  -  -  -  -  211 

Technique        ---..-.  212 

Gonorrheal  Cystitis  -------  214 

Pyelitis  and  Pyelo-Nephritis  op  Gonorrheal  Origin     -  -  216 

Retention  of  Urine  -  -  -  -  -  -  -  218 

General  Systemic  Complications       .---..  2I8 

Gonorrheal  Rheumatism       -  -  -  -  -  -  218 

Arthralgia  --------  220 

Hydarthrosis  ----...  221 

Acute  Arthritis       -  -  -  -  -  -  -  221 

Polyarthritis  Deformans     .-.---  221 

Mfsctjlar  Rheumatism  -..-..  223 

Gonorrheal  Synovitis  -  -  -  -  -  -  223 

Gonorrheal  Bursitis  ......  223 

Gonorrheal  Periostitis         .---..  224 

Abscesses  containing  Gonococci      -----  224 

Eppects  op  Gonorrhea  upon  the  Skin       -  -  .  -  225 

Cardiac  Complications  op  Gonorrhea         -  -  -  -  226 

Gonococcal  Endocarditis    ------  226 

Gonococcal  Pericarditis      -  -  -  -  -  -  229 

Gonococcal  Myocarditis      ------  229 

Complications  appecting  the  Digestive  System    -  -  -  229 

Gonorrhea  Buccalis  ...--.  230 


XVI 


CONTENTS 


CHAPTER  PAGE 

IX.  THE  COMPLICATIONS  OP  GONORRHEA— co/ifonwed 

Ano-Rectal  Gonorrhea         ......  232 

Indirect  Causes       .......  232 

Direct  Causes  .......  233 

Complications  ....-.-  234 

Luys's  Rectoscope  ......  235 

Technique  --------  237 

Value  of  Reotoscopy  in  Rectal  Stricture  -  -  -  239 

Complications  Affecting  the  Respiratory  Organs  -  -  241 

Nasal  Gonorrhea     -------  241 

Gonococcal  Pleurisy  -  -  -  -  -  -  241 

Complications  Affecting  the  Eye  -----  242 

Exogenous  Ocular  Infections  -  .  -  .  .  242 

Endogenous  Ocular  Infections       -  ...  -  244 

Complications  Affecting  the  Nervous  System     -  -  -  247  " 

Gonococcal  Meningitis        ------  247 

Neuralgia  of  Gonorrheal  Origin     -----  247 

Gonococcal  Myelitis  -.--..  247 

Cerebral  Complications       ......  249 

X.  GONORRHEA  IN  WOMEN  AND  CHILDREN  -            -            -            -  250 
Gonorrhea  in  Women          -            ------  250 

Gonorrheal  Urethritis  in  the  Female      -  -  -  -  252 

Course         ...-----  253 

Para-Urethral  Folliculitis  ------  253 

Treatment  -  -  -  -  -  -  -  -  255 

Gonorrheal  Vaginitis  ......  258 

Gonorrheal  Metritis  and  Cervicitis  -  -  -  -  269 

Gonorrheal  Salpingo- Ovaritis         -  -  -  -  -  263 

Gonorrheal  Peritonitis        ...---  264 

GONORRHEAL   BaRTHOMNITIS      ------  264 

Gonorrhea  in  Children         -  -  -  -  -  -  -  266 

Indirect  Causes  ,.-----  266 

Direct  Causes  -  -  -  -  -  -  -  266 

Gonorrhea  in  Little  Boys  -  -  -  -  -  -  267 

Gonorrhea  in  Little  Girls  ------  268 

XI.  THE  TREATMENT  OF  ACUTE  GONORRHEA      -     -     -  269 

1.  Prophylactic  Measures  ......  270 

2.  Antiphlogistic  Treatment       ..-.--  272 

3.  Treatment  of  the  Florid  Stage        -  -  -  -  -  275 

1.  Urethro- Vesical  Irrigations       .....  275 

Indications  ....---  276 

Contra-Indications  -  -  -  -  -  -  276 

Technique  --------  277 

Local  Anesthesia    -..----  280 


CONTENTS  xvii 

CHAPTER  PAGE 

XI.  THE  TREATMENT  OF  ACUTE  GO^ORURE A— continued 

Irrigator  or  Syringe  ?         -            -            -            -            -            -  281 

Should  a  Catheter  be  used  ?-.--.  282 

Number  of  Irrigations  required    -            -            -            -            .  283 

On  the  Action  of  Potassium  Permanganate         ...  283 

Other  Drugs  used  for  Irrigations  -            -            .            -            .  284 

2.  Urethral  Injections         ......  289 

Advantages  and  Drawbacks          -            .            .            .            .  289 

Technique  ----..--  290 

Drugs  used  for  Injections              .....  290 

3.  Balsam  Preparations         ......  292 

Copaiba       -            -            -            -            -            -            -            -  293 

Cubebs        -----...  294 

Sandalwood- Oil       -------  295 

Other  Preparations             ......  295 

Method  of  giving  Balsam  Preparations    ....  296 

4.  Treatment  of  Acute  Gonorrhea  by  Bier's  Method   -            -  297 

4.  Abortive  Treatment     .......  298 

1.  Abortive  Injections          ......  298 

2.  Irrigations  with  Permanganate-            ....  301 

3.  Intra-Urethral  Dressings            .....  303 

4.  Ecouvillonnage  op  the  Urethra            ....  304 

5.  Treatment  op  Acute  Posterior  Urethritis             -            -            -  304 

6.  Sebum  and  Vaccine  Therapy  ......  305 


XII.  THE  TREATMENT  OF  CHRONIC  GONORRHEA 

General  Plan  op  Treatment      .... 
The  Modern  Methods  of  treating  Chronic  Urethritis 

1.  Destruction  op  External  Paba-Ubethral  Foci 

1.  By  Injections  -  -  - 

2.  By  Incision  .... 

3.  By  Means  of  the  Galvanic  Cautery 

2.  Urethro-Vesical  Irrigations       ... 


309 

310 

311 

312 
312 
312 
312 

313 


3.  Urethral  Injections         -           -           -           -           .  -  313 

Permanent  Dressings  -            -            -            -            -  -  314 

Combined  Action  of  Ziac  and  Silver             -            -  -  314 

Action  of  Antiseptic  Gases    -            ...  -  315 

On  the  Insufflation  of  Iodine  Vapours          -            -  -  316 

4.  Massage  op  the  Glands  connected  with  the  Urethra  -  317 

1.  Massage  of  Littre's  Glands       -            -            -            -  -  317 

Indication        -             -             -             -             -             -  -  317 

Technique        -..-...  317 

Vibratory  Massage      -             -            -            -            -  -  319 


xviii  CONTENTS 

CHAPTER  PAGE 

XII.  THE  TREATMENT  OF  CHRONIC  GOl^ ORBME A— continued 

2.  Massage  of  the  Prostate  ....  32O 

Indication         ....--.     320 

Contra-Indication         ......     32O 

Technique        -  -  -  -  -  -  -     320 

Combined  Massage  and  Dilatation     -  -  -  -     321 

Massage  with  Special  Instruments     -  -  -  -     321 

3.  Massage  of  the  Seminal  Vesicles  ....    322 

Indications       -  -  -  -   /  -  -  -     322 

Technique        -  -  -  -  -  -  -  322 

Normal  Vesicular  Contents     -  .  -  -  -     323 

Vesicular  Contents  in  Disease  ....  323 

4.  Massage  of  Cowper's  Glands     .  -  .  -  -  325 

Indications       ..----.  325 

Technique        .--....  325 

6.  Dilatation  of  the  Urethba         .  -  -  .  .  326 

Indication        ..--..-  327 

Preparation  of  the  Patient     -----  327 

1.  Temporary  Dilatation  of  the  Meatus  -  -  327 

2.  Meatotomy       -  -  -  -  -  -  328 

General  Rules  for  Dilatating  the  Urethra  -  -  -  329 

Dilatation  by  Means  of  Curved  Sounds   -  -  -  -  330 

How  many  Sounds  should  be  passed  ?         -  -  -  332 

What  Intervals  should  elapse  ?  -  -  -  -  332 

On  the  Use  of  Filiform  Bougies        -  -  .  .  333 

Dilatation  by  Means  of  Four-Bladed  Dilators     -  -  -  333 

Description  of  KoUmann's  Dilator     -  -  -  -  334 

Irrigating  Dilators       .---..  336 

Curved  Dilators  ..--..  339 

Dilatation  of  the  Posterior  Urethra  .  .  ;.  .  339 

Technique        ..-.-..  339 

Precautions  required  with  Far-Pushed  Dilatations  -  -  341 

Adjuvant  Methods  to  Dilatation  -  .  -  -  -  343 

Complementary  Urethrotomy  ....  344 

Electrolysis      .------  345 

6.  Urethroscopic  Treatment  -  -  -  -  -  346 

1.  Localized  .Application  of  Caustics         -  -  -  -  347 

Technique        ..-.---  347 

Substances  used  ._....  348 

Indications       ..-----  349 

Contra-Indications       ------  349 

2.  Urethroscopic  Treatment  of  Inflamed  Lacunse  and  Follicles  -  350 

Indications       -------  351 

Technique        -------  351 

1.  Glandular  Electrolysis  .  -  .  .  351 

2,  Destruction  with  the  Cautery  -  -  -  353 

3.  Cauterization  by  Means  of  the  Galvanic  Cautery       -  -  354 

Indications       ...-.--  355 

Contra-Indications       ------  355 

Technique        ...----  356 

Untoward  Effects        -  -  -  -  -  -  358 

Results  -------  359 


CONTENTS  xix 

CHAPTER  PAGE 

Xn.  THE  TREATMENT  OF  CHRONIC  GONORRHEA— con^wwed 

4.  Endoscopic  Surgical  Incisions  -----  361 

5.  Curetting  of  Urethral  Strictures            .             -             -             .  363 

7.  Instillations           .---...  364 

Indications       --.--..  364 

Instrumental  Outfit     --..-.  365 

Technique        -             -            -            -            -            -            -  365 

8.  Application  op  Heat  to  the  Urethral  Mucous  Membrane   -  367 

Application  of  Heat  to  the  Prostate              ...  368 

9.  Ionization  Treatment       --....  369 

10.  Salves  and  Urethral  Suppositories       -            .            .            .  371 

Urethral  Salves            .-.-..  371 

Urethral  Suppositories  (Medicated  Bougies)               -             -  372 

11.  Electrolysis  of  the  Urethral  Mucous  Membrane      -            -  372 

Indications       ----...  372 

Technique        -             -             -             -             -             -             -  373 

RfisuME  of  the  Treatment  of  Chronic  Urethritis     ...  375 

Index           -            -            -            -            -            -            -            -            -  377 


GONORRHEA 

CHAPTER  I 

THE  HISTORY  OF  GONORRHEA^ 

Gonorrhea  is  as  old  as  mankind,  and  urethral  discharges  have,  no  doubt, 
been  known  at  all  times.  In  the  primitive  ages,  before  medical  science  had 
originated,  the  wise  legislator  gave  legal  sanction  to  suitable  hygienic 
measures,  and  thus  we  find  Moses  laying  down  laws  for  the  conduct  of  those 
who  suffered  from  a  discharge  from  their  urethra. 

This  oldest  description  of  gonorrhea  dates  back  to  the  fifteenth  century 
B.C.,  and  runs  as  follows  (Lev.  xv.  2,  3): 

"  Speak  unto  the  children  of  Israel,  and  say  unto  them.  When  any  man 
hath  a  running  issue  out  of  his  flesh,  because  of  his  issue  he  is  unclean. 

"  And  this  shall  be  the  uncleanness  in  his  issue :  whether  his  flesh  run 
with  his  issue,  or  his  flesh  be  stopped  from  his  issue,  it  is  his  uncleanness." 

In  the  following  verses  Moses  adds  that  the  uncleanness  is  not  confined 
to  the  person  of  the  patient.  His  bed,  his  seat,  the  articles  he  uses,  and 
the  people  with  whom  he  comes  into  actual  contact,  share  his  uncleanness. 
Moses  was  thus  perfectly  aware  of  the  contagious  nature  of  gonorrhea,  and 
he  desired  that  the  patient  should  allow  a  full  week  to  elapse  after  his  cure 
before  he  attended  to  his  sacrifice  of  atonement  and  resumed  his  social 
functions. 

Anglada  2  states  that  gonorrhea  was  one  of  the  most  important  diseases 
which  prevailed  amongst  the  Jews,  and  this  is  not  astonishing,  considering 
their  unhygienic  mode  of  living  and  their  sexual  incontinence,  of  which 
history  gives  many  examples.  It  may  be  mentioned,  by  the  way,  that 
circumcision  was  invented  for  the  purpose  of  guarding  against  balano- 
posthitis,  one  of  the  commonest  complications  of  gonorrhea. 

The  first  scientific  document  dealing  with  this  disease  was  written  fully 
twelve  centuries  later  (300  B.C.).     In  the  Lectures  of  Hippocrates,  which 

1  Dr.  Roucayrol  has  made  a  special  study  of  the  history  of  gonorrhea.  The  facts 
mentioned  in  this  chapter  are  largely  taken  from  his  most  interesting  thesis  :  Considera- 
tions Historiques  sur  la  Blennorragie,  Paris  (Steinheil),  1907. 

2  Anglada,  Etude  sur  les  Maladies  Eteintes  et  les  Maladies  Nouvelles,  Paris,  1869. 

1 


2  GONOKKHEA 

have  been  handed  down  and  enlarged  by  his  pupils,  we  have  the  first  scientific 
observation. 

"  No  disease,"  says  Hippocrates,  "  has  more  varied  symptoms  than 
strangury.  [This  is  his  term  for  acute  gonorrhea,  and  perhaps  also  for 
cystitis.]  It  is  most  commonly  found  in  youths  and  in  old  men.  In  the 
latter  it  is  always  more  rebellious,  but  nobody  dies  from  it  {De  Locis 
Affectis,  c.  xxix.).  Its  usual  causes  are  renal  suppuration,  and  inflam- 
mation of  the  bladder,  urethra,  rectum,  and  womb,  constipation,  and 
excessive  indulgence  in  the  pleasures  of  Venus. 

Hippocrates  had  dissected  urethrse  affected  with  discharge,  and  had,  no 
doubt,  seen  polypi,  for  he  attributed  the  origin  of  the  disease  to  tubercles 
and  fleshy  proliferations.  He  therefore  taught,  in  accordance  with  his 
ideas  on  inflammation,  that  "  those  suffering  from  tubercles  and  carnosities 
in  their  fvpe  will  get  well  hy  suppuration  and  the  flow  of  pus  " — an  unhappy 
idea  which  misled  humanity  for  many  centuries. 

All  the  great  thinkers  of  those  days  took  a  keen  interest  in  medicine, 
and  allude  to  gonorrhea  in  their  writings.  Aristotle,  Plato,  Seneca,  etc., 
were  well  acquainted  with  this  disease,  and  Epicurus,  the  gay  philosopher, 
suffered  from  it  all  his  life.  After  having  struggled  for  fourteen  days 
against  an  attack  of  acute  retention  which  he  hoped  to  relieve  by  living 
in  a  bath,  he  put  an  end  to  his  misery,  which  had  been  brought  on  by  his 
numerous  strictures,  by  committing  suicide  (Seneca,  Letters  66  and  92). 

Celsus,  who  lived  in  the  times  of  Augustus,  was  the  first  to  attribute  the 
discharge  of  gonorrhea  to  an  ulceration  of  the  urethra  {De  Medicina,  lib.  v.), 
and,  influenced  by  Hippocrates'  teaching,  he  said  that  "  those  whose  urethrse 
have  become  the  seat  of  little  tumours  are  restored  to  health  as  soon  as 
the  pus  is  evacuated  from  the  canal."  Celsus  catheterized  his  patients, 
the  women  as  well  as  the  men,  and  gave  descriptions  of  his  instruments  and 
of  his  modus  operandi. 

The  beginning  of  the  Second  Century  of  our  era  is  marked  by  two  great 
names — Galen  and  Areteeus  of  Cappadocia.  Galen  is  the  inventor  of  the 
term  "  gonorrhea  "  (from  701^?;,  semen,  and  pelv,  to  flow),  his  opinion  being 
that  the  disease  was  merely  an  involuntary  loss  of  sperma,  unaccompanied 
by  erection. 

Aretseus,  on  the  other  hand,  distinguished  clearly  between  spermatorrhea 
and  urethral  discharges  in  his  treatise  De  Signis  et  Causis  Diuturnorum 
Morhorum. 

In  the  chapter  deahng  with  vesical  affections,  he  speaks  of  a  thick  white 
discharge  which  accompanies  acute  cystitis.  He  describes  this  ailment  at 
length,  and  attributes  the  sharpness  of  the  pain  to  the  peculiar  anatomical 
formation  of  the  bladder  which  he  considers  to  be  a  "  flat  nerve." 

For  the  treatment  of  the  discharge,  he  applied  astringents  to  the  bladder. 


THE  HISTORY  OF  GONOERHEA  3 

placed  cooling  substances  in  the  loins,  and  wrapped  the  genitals  and  neigh- 
bouring parts  in  wool.  He  used  embrocations  made  of  rose-oil,  or 
oil  of  dill,  or  of  aromatic  white  wine.  He  was  also  fond  of  ordering 
poultices  composed  of  barley  flour,  erymum  seeds,  a  small  amount  of 
nitre,  and  sufficient  honey  to  make  a  paste.  Sexual  abstinence  and  pro- 
longed cold  baths  completed  these  prescriptions,  which  were  supposed  to 
cure. 

Paul  of  Egina,  in  the  Fourth  Century,  devotes  a  special  chapter  in  his 
Surgery  to  paraphimosis.  "  Paraphimosis  {7rapa(})L/iio(Ti'i),"  he  says,  "  occurs 
with  inflammation  of  the  privates ;  when  the  skin  is  drawn  back,  the  swollen 
glans  can  no  longer  receive  the  prepuce." 

In  the  Sixth  Century,  Ccelius  Aurelianus  {De  Morhis  Chronicis  et  Acutis) 
regarded  purulent  discharges  from  the  urethra  as  a  flow  of  watery  semen, 
due  to  errors  of  diet,  fatigue,  and  sexual  excess. 

Amongst  the  Orientals,  Susruta  is  one  of  the  oldest  Hindu  writers  on 
medicine.  In  one  of  his  works,  which  was  probably  written  long  before  the 
Ninth  Century,  he  deals  with  Diseases  of  the  Urinary  Passages  (Utiara 
St'Hana),  and  devotes  a  chapter  to  dysuria,  for  which  he  advises  medical 
treatment. 

Rhases,  in  the  Ninth  Century,  gave  a  fuller  account  of  gonorrhea  than 
his  predecessors.  His  description  of  urethral  discharges  is  not  without 
interest,  and  he  is  the  first  author  to  point  out  the  occurrence  of  hematuria 
in  cases  in  which  the  bladder  becomes  involved.  His  treatment  was  chiefly 
antiphlogistic  in  the  beginning.  Later  on  he  injected  the  urethra  with 
honeyed  water,  psillum  mucilage,  or  decoction  of  quince  seeds,  and  finally 
he  healed  it  with  white  of  lead  or  antimony.  The  pain  on  making  water 
was  relieved  by  him  with  injections  of  warm  vinegar,  which  apparently  gave 
prompt  relief,  or  by  means  of  rose-water  containing  opium,  which  he  injected 
into  the  bladder.  He  also  gave  large  doses  of  the  last-mentioned  anodyne 
by  the  mouth  (Roucayrol,  loc.  cit.,  p.  26). 

Mesne,  in  the  Tenth  Century,  was  familiar  with  the  works  of  Hippocrates, 
and  was  under  his  influence:  "All  inflammatory  tumours  formed  in  the 
,  passage  and  channel  of  the  urine  produce,  at  first,  pain  accompanied  by 
strangury;  then  pus  is  formed,  and  as  it  flows  the  inflammatory  tumours 
and  the  strangury  are  dispersed."  Farther  on  he  speaks  of  the  erections 
which  accompany  the  discharge. 

Avicenna,  in  his  Canons,  mentions  retention  of  urine  due  to  ulcerations 
of  the  neck  of  the  bladder,  or  due  to  vegetations.  He  passed  catheters  on 
his  patients,  and  irrigated  their  bladders  with  a  silver  syringe.  Strangely 
enough,  he  combined  this  rational  therapy  with  weird  and  outrageous 
prescriptions,  such  as  the  introduction  of  a  flea  into  the  meatus  (Roucayrol, 
loc.  cit.,  p.  30). 


4  GONOEKHEA 

Constantinus  Africanus  (1015-1087)  used  liuman  milk,  oil,  and  barley- 
water,  for  urethral  injections. 

Tlie  excellent  dietic  prescriptions  of  tlie  school  of  Salerno  contained  an 
aphorism  which  indicates  a  very  true  and  useful  prophylactic  measure : 

"  Post  coitum  si  mingas 
Apte  servabis  urethras." 

In  the  Middle  Ages,  Roger  (Thirteenth  Century)  taught  in  his  Surgery 
that  gonorrhea  is  characterized  by  pain,  burning,  redness,  and  swelling  of 
the  penis,  and  by  difficulty  in  making  water.  His  therapy  was  a  fairly 
active  one ;  he  bled  his  patients  from  the  saphenous  vein,  and  applied  leeches. 
He  also  practised  injections  per  algariam.  His  aim  was  to  produce  suppura- 
tion, because  Hippocrates  had  said  that  those  who  have  pustules  in  their 
penis  get  well  by  suppuration.  He  was  also  acquainted  with  gonorrheal 
orchitis,  but  did  not  leave  any  details  about  his  treatment  of  this 
complaint. 

His  contemporary,  Gruillaume  de  Salicet,  attributed  the  discharge  to 
filth  retained  under  the  prepuce  after  connection  with  a  dirty  woman.  He 
treated  the  ulcers  formed  by  means  of  the  cautery,  in  order  to  "  separate  the 
corrupt  from  the  healthy."  He  stands  out  amongst  the  people  of  his  time 
by  being  the  first  to  study  the  question  of  prophylaxis ;  he  advises  washings 
with  water  after  every  suspicious  connection. 

Lanfranc,  his  pupil  (Thirteenth  Century),  deals  in  his  Surgery  with  the 
afostumes  of  the  generative  organs,  which  he  attributes  to  hot  or  to  cold 
humours.  Painful  erections  are,  in  his  opinion,  due  to  the  fact  that  "  the 
penis  is  full  of  flatus  surmounted  by  great  pain."  He  treated  by  letting 
blood,  on  the  first  day  from  the  arm,  and  on  the  second  from  the  ankle. 
He  forbade  wine,  meat,  and  "  sweet  things."  He  also  prescribed  a  number 
of  salves  which  he  considered  very  wonderful.  Orchitis,  or  "  Tapostume 
froict,"  as  he  called  it,  was  treated  by  him  with  suppositories.  For  indura- 
tions he  had  a  special  salve  which  had  given  him  good  results ;  and  painful 
erections  were  dealt  with  by  anointing  the  penis  with  a  special  ointment, 
which  had  proved  "  very  profitable  "  in  his  experience. 

He  did  not  confine  himself  to  curing;  he  also  advised  certain  prophy- 
lactic measures.  Those  who  had  run  the  risk  of  contamination  were  recom- 
mended to  wash  with  equal  parts  of  water  and  of  vinegar.  He  even  went 
farther,  and  advised,  on  the  strength  of  his  personal  experience,  "  to  wash 
the  part  of  its  own  urine." 

Gordon's  LUium  Medicine  (Thirteenth  Century)  contains  but  rudimentary 
information.  Gonorrhea  is  explained  as  a  flow  of  semen,  unaccompanied 
by  pleasant  sensations,  which  may  be  caused  by  sexual  excesses  or  by 
"  having  sat  on  a  cold  stone  "  !     Gordon  treated  his  patients  by  blood- 


THE  HISTORY  OF  GONOERHEA  5 

letting,  by  making  them  vomit,  and  by  giving  them  a  rose  syrup.  He  also 
recommended  a  diet  consisting  of  gruel,  lentils,  etc.,  and  advocated  bathing 
of  the  loins  and  of  the  genitals  with  cold  water.  For  patients  suffering  from 
retention  he  ordered  baths,  and  completed  their  beneficial  effect  by  putting 
living  or  powdered  fleas  on  the  penis  (Roucayrol,  he.  cit.,  p.  44). 

John  of  Gaddesden,  Professor  at  Oxford,  and  a  contemporary,  followed 
in  his  footsteps.  He  also  recommends  prophylactic  washings  after  every 
suspicious  intercourse,  in  his  book  Rosa  Anglica  Practica  MediccB.  These 
washings  were  to  be  made  with  acidulated  water,  or  with  urine  if  no  water 
was  obtainable.  Gaddesden  is  the  first  to  mention  suspensory  bandages : 
Ne  suspensio  noceat  fascondo  currere  materiam  ad  locum. 

Guy  de  Chauliac,  at  the  end  of  the  Fourteenth  Century,  took  over  the 
suspensory  bandage  from  John  of  Gaddesden:  "And  the  bandages  for 
support  shall  be  made  in  the  shape  of  a  sachet,  with  the  truss  arranged 
in  such  a  way  that  they  hold  and  support  without  causing  any  pain." 
Like  Avicenna,  he  treated  the  discharge  with  antiphlogistics.  In  priapism 
he  saw  a  symptom  of  the  disease,  but  he  described  it  in  a  special  chapter, 
and  explained  it  in  accordance  with  Galen's  teachings.  Erections  he 
believed  to  be  due  to  a  "  vaporous  flatus,"  but  added  that  they  are  "  also 
very  often  caused  by  dilatation  of  the  arteries  of  the  penis." 

He  treated  painful  erections  by  means  of  camphor,  Galen's  wax  salve, 
and  by  placing  a  sheet  of  lead  on  the  organ. 

Following  Galen  and  Rhases,  the  first  step  of  his  treatment  for  retention 
was  to  prescribe  cantharides.  Then  came  "  baths  with  embrocations, 
plasters,  salves,  and  lotions,  which  were  applied  to  the  mons  Veneris,  the 
penis,  and  the  perineum."  He  also  advocated  Master  Gordon's  practice, 
"  who  gave  injections  and  syringations  into  the  bladder  with  balsams." 
His  prescriptions  were  largely  of  a  disgusting  and  revolting  character.  He 
believed  the  excreta  of  pigeons  to  be  an  excellent  drug,  and  considered  the 
application  of  a  flea  or  louse  to  the  meatus  of  great  importance  (Roucayrol, 
loc.  cit.,  p.  48). 

Valescus  of  Tarentum,  in  the  beginning  of  the  Fifteenth  Century,  attrib- 
uted urethral  discharge  to  intercourse  with  a  dirty,  vile,  or  chancrous  woman, 
or  to  too  frequent  intercourse  {Philonium  PJiarmaceutium  et  Chirurgicum). 
He  also  held  that  "  the  sharpness  of  the  urine  leads  to  the  formation  of 
ulcers,  if  it  lasts  long  enough,"  and  believed  it  to  be  due  to  ulcerations 
present  in  the  bladder  andin  the  glans  (Roucayrol,  loc.  cit.,  p.  53). 

Peter  of  Argelata  speaks  in  his  Surgery  (Fifteenth  Century)  of  pustules 
which  break  out  on  the  penis  after  intercourse  with  diseased  women,  and 
recommends  to  wash  the  patient  with  water  in  the  summer,  and  with  urine 
in  the  winter.  Restrictions  in  the  diet,  purgation,  soothing  applications 
of  olive-oil,  poplar-tree  ointment,  or  barley  poultice,  and  a  salve  composed 


6  GONORKHBA 

of  breadcrumbs  soaked  in  milk  and  mixed  witb  yolk  of  egg,  complete  bis 
therapy,  not  to  mention  the  inevitable  fumigations  and  embrocations. 

About  the  same  time  Marcellus  Cumanus  claimed  to  have  cured  many 
patients  by  his  method,  which  consisted  of  purgation,  low  diet,  and  inunc- 
tions with  olive-oil.  He  also  advocated  to  inject  cow's  or  goat's  milk,  or, 
better  still,  human  milk,  into  the  urethra — an  advice  which  he  considered  to 
be  marvellous. 

His  contemporary,  Antonius  Guainer,  recommended,  in  his  chapter  on 
Retention  of  Urine,  the  introduction  of  a  small  wax  bougie,  or  of  a  little 
sound  made  of  silver  or  tin,  into  the  urethra.'  He  appears  to  have  been 
very  familiar  with  this  method,  and  is  the  first  to  mention  treatment  by 
dilatation,  and  thus  his  name  deserves  to  be  handed  down  to  posterity. 

Arculanus  (Fifteenth  Century)  laid  down  some  extremely  interesting 
remarks  in  his  Treatise  on  Surgery.  His  prognosis  of  acute  gonorrhea  is. 
curious;  he  points  out  the  gravity  of  the  illness  in  the  aged.  He  was  the 
first  to  describe  the  properties  of  silver  in  the  treatment  of  cystitis,  and 
ordered  irrigations  of  the  bladder  with  silver.  He  forbade  sexual  inter- 
course, advised  antiphlogistic  treatment,  and  gave  lengthy  directions  about 
the  diet  to  be  followed.  In  his  chapter  on  Diflficult  Micturition  he  gives 
definitions  of  dysuria  and  ischuria,  the  former  denoting  di£S.culty,  the  latter 
impossibility,  of  micturition.  He  speaks  of  voluntary  retention  caused  by 
the  pain  experienced  with  ulcerations  of  the  penis,  and  teaches  that  reten- 
tion of  urine  may  be  due  to  a  wart,  or  to  formation  of  flesh  within  the  pipe 
causing  "  a  fleshy  obstruction."  He  recommends  to  investigate  the  origin 
of  the  retention  by  passing  a  sound,  and  gives  some  very  interesting  details 
about  his  instrumental  outfit. 

Vigo's  book  (beginning  of  the  Sixteenth  Century)  marks  an  important 
date  in  the  history  of  gonorrhea.  Vigo  made  a  clear  distinction  between 
gonorrhea  and  syphilis.  The  latter  disease  made  its  first  appearance  in 
1494,  according  to  him.  "  In  the  year  in  which  King  Charles  VIII.  wished 
to  recover  the  kingdom  of  Naples,  appeared  in  the  month  of  December,"  etc. 

His  pupil  Marianus  Sanctus  deals  in  the  last  part  of  his  work  De  Lapide 
Rennum  et  Vesicce  with  the  history  of  strictures,  and  mentions  cases  which 
did  not  even  admit  a  sound  "  syringam."  He  advocated  for  their  treat- 
ment an  instrument  (Fig.  1)  which  he  appears  to  have  invented,  and  which 
he  calls  "  terlinum  "  or  "  rostrum  arcuatum."  This  instrument  was  to  be 
of  suflB.cient  length  to  reach  the  neck  of  the  bladder,  and  deserves  to  be 
compared  with  Oberlander's  dilator  (Fig.  2). 

Rabelais,  in  the  Sixteenth  Century,  was  also  well  acquainted  with  gonor- 
rhea, and  many  of  our  readers  will  remember  the  doleful  paragraph  in  which 
he  refers  to  it  :  "Poor  old  Pantagruel  fell  ill,  and  his  stomach  got  so  out  of 
order,  that  he  could  neither  eat  nor  drink.     And  as  no  evil  comes  alone,  he 


THE  HISTORY  OF  GONORRHEA  7 

also  caught  the  clap,  which  tormented  him  more  than  you  would  believe. 
But  his  doctors  stood  by  him  gallantly,  and  with  many  emollient  and 
diuretic  drugs  made  him  piss  away  his  misfortune  "  (lib.  ii.,  cap.  28). 

Up  to  this  time  all  the  authors  were  perfectly  aware  that  gonorrhea 
and  syphiHs  are  two  distinct  diseases.  The  confusion  was  started  by 
Brassavole,  whose  book  Examen  Omnium  Loch  de  Morbo  Gallico  Tractus 


Pig.  1, — ^Marianus  Sanctus'  Terlintjm  ob  Rostrum  Arcuatum. 
(Roucayrol.) 

appeared  in  1551.  Like  his  predecessors,  he  dated  the  outbreak  of  syphilis 
back  to  the  siege  of  Naples,  but  he  considered  gonorrhea  to  be  merely  a 
manifestation  of  syphilis. 

Alphonso  Eerri  wrote  in  1548  a  special  work  on  strictures,  which  was  a 
great  improvement  on  the  former  writings  on  this  subject.  It  resumes 
the  experience  which  he  acquired  during  his  long  professorship  of  surgery 
in  Italy,  and  is  entitled  De  Caruncula  sive  Callo  quce  Cervici  Vescice  innas- 
cuntur  liber. 

Amongst  the  conditions  which  give  rise  to  caruncles,  he  mentions 
gonorrhea.    This  disease  may  produce  ulcerations  anywhere  in  the  urethra, 


Fig.  2. — Oberlander's  Dilator. 


and  thus  caruncles  may  be  present  in  any  of  its  parts.  The  caruncle  can  be 
softened  by  means  of  medicines,  fomentations,  poultices,  salves,  and 
emollient  injections.  Then  a  bougie  is  passed,  after  it  has  been  lubricated 
with  "  cow's  butter  or  buffalo  butter,  almond,  sesam,  or  ordinary  oil,  or 
goose  or  duck  fat."  The  operator  selects  a  suitable  bougie,  covers  it  by 
means  of  his  finger  with  one  of  the  substances  indicated,  and  introduces  it. 
Ferri  warns  against  the  use  of  corrosive  remedies  in  a  liquid  or  soft  form, 
because  they  affect  the  healthy  parts  as  well  as  the  diseased  focus ;  and  as  the 


8  GONOERHEA 

former  are  of  a  weak  constitution,  they  would  sulier.  A  preparation  of  suffi- 
cient hardness  is  required  which  can  be  applied  to  the  caruncle  without 
damaging  any  other  part  over  which  it  has  to  pass.  "  One  should,  however, 
not  forget,"  says  Ferri,  "  that  the  older  the  caruncle,  the  more  difficult  it  is 
to  cure,  and,  therefore,  gradually  stronger  remedies  have  to  be  tried  if  the 
milder  ones  have  failed.  If  topics  be  insufficient  to  destroy  the  caruncle, 
one  has  to  resort  to  the  use  of  an  argaly,  or  of  a  pointed  and  cutting  sound, 
in  order  to  penetrate  more  readily.  The  flow  of  blood  caused  by  these 
instruments  should  not  cause  alarm;  it  is  even  most  beneficial,  providing 
the  blood  comes  from  the  caruncle,  and  not  from  any  other  part.  Whether 
this  is  so  can  always  be  made  out  easily,  because  one  can  feel  if  the  point 
of  the  argaly  or  of  the  sound  is  in  contact  with  the  caruncle,  in  which  case 
the  operation  is  most  successful.  The  subsequent  flow  of  urine  cleanses 
and  dries  the  tissues,  and  thus  leads  to  cicatrization,  no  further  intervention 
being  required." 

In  the  Sixteenth  Century,  Lacuna  wrote  a  treatise  on  the  same  subject — 
Methodus  Cognoscendi,  extirpandique  in  VesiccB  Collo  Carunculas.  He  de- 
scribes bougies  which  melt  after  they  have  been  introduced.  He  says  that 
they  are  beyond  praise,  and  that  they  consume  all  ulcers  and  carnosities 
without  causing  much  pain.  He  also  gives  a  list  of  the  cases  of  venereal 
strangury  which  he  cured  with  his  bougies. 

Ambroise  Fare's  celebrated  work  Des  Chaudes-fisses  et  Carnositez 
engendrees  au  Meat  Urinal  appeared  in  1564. 

It  deals  mainly  with  syphilis,  but  the  causes  of  gonorrhea  are  men- 
tioned: "  The  clap  is  due  to  three  causes — overeating,  starvation,  and 
infection.  It  comes  on  after  intercourse  with  a  woman  who  has  had  some 
ulcer  about  her  privates,  some  syphilitic  matter." 

Pare  thus  confounded  gonorrhea  and  syphilis,  and  this  mistake  prevailed 
until  the  beginning  of  the  Nineteenth  Century. 

Ambroise  Pare  resumed  his  treatment  of  gonorrhea  as  follows:  "  A 
learned  doctor  should  be  called  in,  and  he  should  bleed  and  purge  the 
patient,  if  necessary,  and  direct  the  diet."  He  forbade  all  rich  food,  wine, 
and  the  company  of  women,  "  even  to  see  them  in  paintings  or  otherwise." 
Cold  baths,  as  little  sleep  as  possible,  and  a  certain  refreshing  plaster  which 
was  to  be  applied  to  the  loins  and  to  the  genitals,  he  considered  useful.  He 
recommended  the  use  of  turpentine  with  emphasis,  as  he  believed  it  to  be 
an  excellent  drug  for  gonorrhea.  Apart  from  turpentine,  he  ordered  his 
patients  to  avoid  "  all  things  which  heat  the  blood,"  and  violent  exercise. 
They  had  to  sleep  on  a  hard  bed,  and  to  drink  lemon-juice  or  barley-water. 

He  alleviated  the  pain  on  micturition  during  the  acute  stage  by  recom- 
mending the  patient  to  micturate  "  into  a  vessel  containing  warm  milk,  in 
which  he  dips  his  penis  whilst  he  makes  water.     If  no  milk  is  at  hand. 


THE  HISTOKY  OF  GONOEEHEA  9 

warm  water  shall  be  used  instead."  After  the  acute  stage  had  subsided, 
Pare  advised  injections  containing  aromatic  wine,  aloes,  hydromel,  and 
absinth. 

For  chronic  urethritis  he  recommended  urethral  dressings  consisting  of 
an  ointment,  which  was  applied  with  a  little  wax  candle  or  sound  wrapped 
in  a  piece  of  linen. 

Ambroise  Pare  made  large  use  of  dilatation  treatment  for  chronic 
inflammation  of  the  urethra.  He  was  the  first  to  dwell  upon  the  necessity 
of  using  the  "  biggest  sounds  which  the  patient  can  endure  "  in  order  to 
obtain  a  good  result. 

Loyseau,  in  the  Sixteenth  Century,  followed  Ambroise  Pare.  He  treated 
Henry  IV.  of  France  for  stricture,  and  gave  his  royal  patient  great  relief 
by  introducing  an  ointment  into  his  urethra  by  means  of  a  bougie.  The 
victor  of  Ivry  was  so  delighted  that  he  bought  it  for  him,  and  raised  him 
to  the  rank  of  a  Count. 

Fabricius  d'Aquapendente  published  in  1649  an  important  work  in 
which  he  deals  with  "  urethral  ulcer  due  to  gonorrhea."  He  was  chiefly 
concerned  with  the  treatment  of  strictures,  and  the  same  may  be  said  of  Van 
Helmont,  Fran9ois  Tolet,  Van  Solingen,  Dionis,  in  the  Seventeenth  Century. 

The  knowledge  of  the  pathology  of  urethral  inflammation  made  great 
strides  under  Morgagni.  He  was  the  first  to  show  that  the  discharge  was 
not  caused  by  ulcerations  in  the  urethra,  and  he  put  an  end  to  the  old  fallacy 
which  dated  from  Galen,  by  proving  the  discharge  to  take  its  origin  from  the 
urethral  mucous  membrane,  and  not  from  the  seminal  vesicles.  He  dis- 
covered the  "  lacunae  of  Morgagni,"  and  pointed  out  the  importance  of 
their  inflammation  in  chronic  gonorrhea. 

ToCardanus(EighteenthCentury)we  owe  a  good  description  of  gonorrhea. 
He  discusses  acute  retention  under  the  term  of  "  dry  clap."  Orchitis  is, 
in  his  opinion,  due  to  the  fact  that  "  the  clap  has  fallen  into  the  scrotum." 
Like  all  his  contemporaries,  he  was  unable  to  distinguish  between  gonorrhea 
and  syphilis,  and  therefore  treated  the  former  with  mercury,  chiefly  by 
internal  administration  of  the  perchloride.  For  gonorrheal  epididymitis 
he  resorted  to  castration. 

John  Hunter,  in  the  same  century,  was  the  first  to  undertake  inocula- 
tion experiments  for  the  purpose  of  studying  the  evolution  of  the  malady. 
His  disastrous  auto-inoculation,  through  which  he  ax3quired  gonorrhea  and 
syphiHs  simultaneously,  led  him  to  proclaim  the  identity  of  these  two 
diseases,  and  he  remained  a  passionate  defender  of  this  error  until  his  death. 
Towards  the  very  end  of  the  century,  in  1793,  Benjamin  Bell  established 
the  distinction  between  gonorrhea  and  syphilis.  According  to  him,  the  former 
was  a  purely  local  infection  caused  by  some  special  contamination  which 
differed  from  syphilitic  infection. 


10  GONOREHEA 

His  views  were  taken  up  in  France  by  Bosquillon. 

Swediaur  invented  the  term  "  blennorrhagie  "  (from  /3X€vva,  mucus), 
now  adopted  in  France,  and  produced  urethral  discharges  experimentally 
by  injecting  irritating  chemicals,  such  as  ammonia,  into  the  urethra. 

Hernandez  of  Toulon  undertook  his  famous  inoculation  experiments 
in  1812.  He  inoculated  seventeen  convicts,  and  demonstrated  thus  that 
inoculation  of  gonorrheal  material  produces  gonorrhea,  and  is  never  followed 
by  syphilitic  lesions. 

The  definite  separation  of  the  two  diseases,  however,  dates  from  Ricord 
(1831),  who  in  his  lucid  and  vigorous  writings  and  lectures  spread  the  new 
truth.  He  was  the  first  to  show  that  the  manifestations  of  syphilis  are 
ushered  in  by  the  appearance  of  a  chancre,  Ricord's  "  accident  primitif," 
and  grouped  the  subsequent  symptoms  into  "  secondary  "  and  "  tertiary." 
He  demonstrated  over  and  over  again  the  characteristic  differences  between 
these  two  diseases,  and  proved  conclusively  that  an  attack  of  gonorrhea 
cannot  develop  into  syphilis. 

In  Ricord's  opinion,  gonorrhea  was  a  simple  inflammation  of  the  urethral 
mucous  membrane  which  could  be  brought  on  by  various  ill-defined  causes. 
His  non-specific  phlogogenic  theory  of  its  origin  was  widely  accepted  by  his 
contemporaries. 

Rollet  of  Lyons,  however,  opposed  him,  and  proclaimed  the  disease  to 
be  caused  by  a  specific  virus.  He  held  that  every  case  of  gonorrhea  owed 
its  existence  to  another  case  of  gonorrhea  from  which  it  had  received  the 
virus,  which  was  still  unknown. 

Whilst  the  war  was  still  waging  between  the  followers  of  Ricord  and 
those  of  Rollet,  bacteriological  research  had  made  sufiicient  progress  to 
tackle  the  problem. 

In  1872  Hallier  discovered  the  presence  of  micro-organisms  in  the 
pus  cells  of  gonorrheal  discharge,  and  in  1879  Albert  Neisser,  then  assistant 
in  the  Breslau  Dermatological  Clinique,  discovered  the  gonococcus. 

To  Neisser  belongs,  not  only  the  credit  of  having  discovered  the  specific 
organism,  and  of  having  described  it  fully  and  accurately,  but  he  also  proved 
it  to  be  the  pathogenic  factor  in  all  cases  of  ocular  and  urethral  gonorrhea. 

Neisser's  researches  were  confirmed  by  Bakei  and  Finkelstein,  Watson- 
Cheyne,  Haab,  and  others.  In  1884  Bumm  succeeded  in  making  pure  cul- 
tures of  Neisser's  gonococcus,  and  Wertheim  invented  a  practical  method 
of  cultivation  shortly  afterwards. 

Amongst  the  great  men  associated  with  the  study  of  gonorrhea,  Desor- 
meaux  deserves  a  special  mention.  As  far  back  as  1854,  the  "  Father  of 
Endoscopy,"  as  he  is  rightly  called,  realized  that  the  treatment  of  urethral 
inflammation  should  be  based  on  an  exact  knowledge  of  the  lesions,  and  he 
invented  for  this  purpose  the  first  urethroscope.     Although  primitive,  this 


THE  HISTORY  OF  GONORRHEA  11 

instrument  was  a  remarkable  invention,  and  represented  the  first  step  to  the 
truly  scientific  treatment  which  we  have  at  our  disposal  nowadays. 

Benique  was  the  first  to  use  the  metal  sounds  which  bear  his  name,  for 
the  treatment  of  urethral  stricture.  His  discovery  was  made  more  than 
seventy  years  ago,  and  we  still  use  his  instruments. 

Civiale  also  believed  in  dilatation,  practised  and  taught  it. 

The  treatment  of  gonorrhea,  such  as  it  was,  in  the  middle  of  the  Nine- 
teenth Century  has  been  well  summed  up  by  Voillemier.  It  consisted — 
(1)  in  aborting  the  inflammation,  if  the  case  comes  under  treatment  in  its 
early  stage;  (2)  in  fighting  it,  once  it  is  well  established;  and  (3)  in  drying  up 
the  discharge  by  modifying  the  secreting  surface  by  means  of  topics. 

To  give  a  full  account  of  all  the  modern  work  on  gonorrhea  in  this 
chapter  would  lead  to  repetition.  Reference  to  recent  writers  is  constantly 
made  in  the  following  chapters.  May  it  suflS.ce  here  to  express  our  admira- 
tion for  the  great  work  done  by  the  German  school,  headed  by  Professor 
Oberlander  of  Dresden.  Thanks  to  him,  the  urethroscopic  method  has 
been  widely  adopted  for  the  diagnosis  of  the  foci  which  keep  up  chronic 
discharges,  and  his  teachings  have  been  made  widely  known  through  the 
important  works  of  Professor  Kollmann  of  Leipzig,  and  of  Wossidlo  and 
Franck  of  Berlin.  I  have  devoted  more  than  twelve  years  to  the  study  of 
their  work,  and  I  have  become  a  passionate  partisan  of  their  doctrines. 


CHAPTEH  II 

THE  DANGERS  OF  GONORRHEA 

Cases  of  gonorrhea  are  seen  every  day  in  general  practice,  so  great  is 
their  frequency,  and  hence  their  great  interest  from  a  social  point  of  view. 

Despite  its  apparent  benignity,  gonorrhea  is  a  formidable  malady  because 
of  its  immediate  and  remote  sequelae.  It  is  a  great  mistake  to  think  that 
"  gleet,"  as  it  is  usually  called,  is  an  insignificant  local  trouble  which  calls 
for  jocular  comment.  One  should  not  forget  that  an  attack  of  gonorrhea 
may  terminate  in  death  ! 

Unfortunately,  even  medical  men  are  to  be  found  who  regard  "  gleet  " 
as  a  benign  disease,  and  who  are  unaware  of  the  fact  that  gonococci  are 
very  frequently  present  in  these  cases.  It  is  true  that  these  gonococci  are 
latent,  and  inconvenience  their  owners,  who  enjoy  towards  them  a  relative 
immunity,  but  little,  if  at  all;  but  they  are  virulent  to  others.  The  proof 
of  this  statement  is  to  be  found  in  the  endless  number  of  cases  of  gonorrhea 
which  were  infected  by  women  who  showed  no  trace  of  disease.  In  these 
cases  one  is  confronted  with  a  special  adaptation  of  the  urethral  soil — with 
a  temporary  local  immunity  which  is  entirely  relative.  It  only  requires  a 
certain  amount  of  fatigue  or  sexual  excess,  connection  during  the  menstrual 
period,  or  an  immoderate  quantity  of  pure  wine,  liqueurs,  or  beer,  to  render 
the  soil  again  favourable,  and  to  allow  the  gonococcus  to  resume  its  activity. 
There  can  be  no  question  of  fresh  infection  in  these  cases ;  they  are  genuine 
relapses. 

Another  very  common  prejudice,  which  is  not  only  prevalent  amongst 
the  laity,  but  also  amongst  medical  men,  is  the  belief  that  only  a  purulent 
discharge,  the  "  morning  drop,"  is  worthy  of  consideration,  and  that  the 
disease  is  cured  once  this  symptom  has  disappeared.  This  is  a  very  serious 
mistake;  for  only  too  often  are  big,  heavy  filaments  present  in  the  urine 
after  the  discharge  has  ceased,  and  these  filaments  are  apt  to  be  carried 
along  with  the  sperma  during  ejaculation  into  the  genito-urinary  organs  of 
the  woman.  Apart  from  the  possibility  of  infecting  her,  these  filaments 
are  a  danger  to  the  man  himself.  They  are  the  products  of  lesions  which 
evolve  insidiously  and  continuously  for  months  and  months,  before  they 
become  obvious  in  the  shape  of  serious  complications. 

12 


THE  DANGERS  OF  GONORRHEA  13 

Gonorrhea  is  thus  a  true  social  scourge  which  affects  the  individual,  the 
family,  and  the  community,  and  therefore  deserves  to  rank  with  syphilis 
from  this  point  of  view. 

To  begin  with,  it  is  a  source  of  disasters  to  the  infected  individual. 
Strictures  of  the  urethra  and  all  their  sequelae,  double  epididymo-orchitis 
leading  to  sterility,  prostatitis  often  complicated  by  retention  of  urine, 
cystitis,  and  pyelonephritis,  are  some  of  the  dangers  which  threaten  the 
ignorant  or  careless  patient.  Then  there  are  the  systemic  complications, 
which  should  never  be  lost  sight  of,  such  as  gonorrheal  rheumatism,  which 
is  present  in  2  per  cent,  of  all  cases,  periostitis,  osteopathy,  and  muscular 
troubles  of  gonococcal  origin.  The  cardiac,  vascular,  pleuro-pulmonary, 
peritoneal,  and  meningitic  complications  observed  by  so  m.any  authors 
prove  conclusively  the  existence  of  a  general  systemic  infection  caused  by 
the  gonococcus. 

The  male  transmits  his  gonorrhea  to  the  woman,  and  it  has  been  estab- 
lished beyond  doubt  nowadays  that  about  70  per  cent,  of  the  bartholinites, 
cystites,  metrites,  and  salpingites,  met  with  in  married  women,  are  due  to 
the  gleet  of  their  careless,  ignorant,  or  unscrupulous  husbands.  Jullien's 
words^  are  only  too  true:  "  Generally,  morbid  conditions  arise  which  are 
of  a  persistent  character,  and  show  no  tendency  to  cure.  The  generative 
organs  become  gradually  involved  to  their  whole  extent ;  the  general  health 
suffers;  all  the  functions  of  the  body  become  slack;  the  women  merely  drag 
along,  and  have  to  pay  for  every  minute  of  exertion,  for  the  shghtest  error 
in  their  diet,  and  for  a  walk  of  any  distance,  with  weeks  of  invalidity.  The 
home  is  childless,  there  is  no  happiness,  and  this  state  of  affairs  may  last  for 
years !" 

The  wife  is  an  invalid  or  sterile,  whilst  the  husband  goes  about  uncon- 
scious of  his  guilt,  and  unaware  of  the  fact  that  he  is  still  contagious  owing 
to  the  discharge  which  he  neglected  in  his  youth,  say  eight,  ten,  or  even 
fifteen  years  previously.  Ricord  treated  in  1840  a  patient  whose  illness 
dated  from  the  year  1800.  Desormeaux  attended  in  1863  an  officer  who  had 
not  been  free  from  urethritis  since  1813.  Hartmann  has  also  had  occasion 
to  con^dnce  himself  of  the  longevity  of  the  gonococcus :  one  of  his  patients 
had  a  chronic  discharge  for  ten  years,  which  had  been  treated  without  success 
in  all  the  capitals  of  Europe.  On  one  occasion  only  this  patient  had  inter- 
course with  a  woman  without  a  preservative :  five  days  later  she  developed 
acute  gonorrhea,  characterized  by  violent  urethritis,  hemorrhagic  cystitis, 
and  metritis.  Finally  a  double  pyosalpinx  supervened,  which  required  a 
mutilating  operation.^ 

How  often  do  we  not  hear  this  doleful  statement  repeated  by  young 

1  JuUien,  Blennorragie  et  Mariage,  Paris  (Bailliere),  1898,  p.  138. 

2  Hartmann,  Organes  Ginito-Urinaires  de  l' Homme  (Steinheil),  1904,  p.  79. 


14  GONOERHEA 

wives:  "  As  a  girl  I  was  very  strong  and  well;  since  my  marriage  my  health 
has  left  me  "  ! 

An  alarmingly  great  number  of  young  women  are  confined  for  months, 
or  even  for  years,  to  their  bed  or  their  sofa,  and  pass  their  days  in  worrying 
over  their  shattered  health.  The  gravity  of  their  lesions  condemns  them 
incessantly  to  all  sorts  of  precautions,  which  may  allow  them  to  lead  a 
life  of  misery  for  some  time,  but  cannot  cure.  Their  only  hope  is  a  serious 
operation,  which  deprives  them  of  their  diseased  organs,  and  renders  them 
sterile  for  ever.  And  those  who  suffer  thus  are  not  only  prostitutes  and 
ladies  of  easy  virtue,  who,  as  Verchere  puts  it,  "  merely  run  the  risks  of 
the  trade,"  but  also  married  women  who  are  absolutely  straight  and  faithful, 
and  have  nothing  to  reproach  themselves  except  a  mistake  in  the  choice 
of  their  husbands.  One  cannot  close  one's  eyes  to  the  fact  that  very  often 
the  parents  are  guilty  of  negligence  or  ignorance  in  these  instances,  and 
that,  unfortunately,  also  the  medical  adviser  is  not  always  free  from  the 
blame  of  having  reported  favourably  on  the  fiance's  health  without  having 
examined  him  with  sufficient  care. 

Then,  again,  the  disease,  brought  into  the  family  by  the  husband,  may 
afiect  the  children  in  the  form  of  purulent  ophthalmia  of  the  new-born, 
condemning  these  poor  little  creatures  to  complete  blindness,  and  rendering 
them  a  burden  to  society.  Gonorrheal  urethritis,  and  especially  vulvo- 
vaginitis, are  not  infrequently  met  with  in  little  girls,  chiefly  amongst  the 
poor,  whose  miserable  hygienic  conditions  (lack  of  cleanliness,  overcrowding, 
etc.)  favour  the  development  of  this  afiection.  Apart  from  those  cases  of 
vulvo -vaginitis  in  which  rape,  criminal  intercourse,  etc.,  are  responsible, 
there  are  plenty  of  instances  in  which  girls  of  tender  age  were  contaminated 
through  the  contact  with  soiled  linen,  infected  sponges  and  bed  clothes,  or 
dirty  thermometers,^  etc. 

The  seriousness  of  this  disease  lies  in  its  tenacity,  and  in  the  difficulty 
of  eradicating  it,  once  it  has  gained  a  footing  in  a  family,  or  in  a  hospital, 
or  in  a  school. 

The  husband  brings  the  germ  homie,  gives  it  to  his  wife,  who  becomes  as 
contagious  as  he  is — Verchere's  "  gonorrhea  of  the  innocent." 

The  pathological  cycle  observable  is,  then,  one  of  the  following:  The 
husband  seeks  treatment,  once  he  finds  his  disease  persisting  or  becoming 
worse.  When  he  is  cured,  he  cohabits  again  with  his  wife,  and  reinfects 
himself.  Or  it  is  the  wife  who,  having  had  since  her  marriage  a  cystitis  or 
a  severe  metritis,  consults  a  doctor  and  obtains  relief.  The  first  intercourse 
with  her  diseased  husband  leads  to  reinfection.  Thus  alternate  reinfections 
ad  infinitum  take  place,  and  it  becomes  impossible  to  Gx  any  date  for  the 

1  Veil  et  Bayon,  "Epidemie  de  Vulvite  a  Gonocoques;  Transmission  par  un  Ther- 
niometre,"  Semaine  Medicale,  1904. 


THE  DANGERS  OF  GONOREHEA  15 

duration  of  tlie  man's  gleet  or  for  the  wife's  metritis.     It  is  not  uncommon 
for  this  state  of  things  to  last  ten  years  or  longer. 

In  cases  of  this  type  the  infection  is  seldom  acute,  and  rarely  produces 
alarming  symptoms.  Bad  cases  are,  however,  met  with,  although  they  are 
very  uncommon,  and  then  they  convert  the  honeymoon  of  the  young  couple 
into  a  gallmoon,  as  Callari  puts  it. 

In  the  vast  majority  of  cases  the  infection  is  attenuated,  or  very  attenu- 
ated even,  and  merely  causes  a  urethritis  or  a  slight  metritis,  which,  never- 
theless, often  renders  the  wife  sterile. 

Paul  Delbet  has  quoted  two  cases  of  this  nature,^  in  which  the  simul- 
taneous disinfection  of  husband  and  wife  was  followed  by  fertilization. 

A  general  outcry  has  been  raised  by  all  those  who  have  studied  the  ques- 
tion, and  they  have  pointed  out  with  emphasis  the  great  danger  of  infection 
connected  with  chronic  gonorrhea.  But  the  terrible  consequences  of  gleet, 
as  far  as  they  concern  married  life,  are  inadequately  known. 

Noeggerath,2  who  was  one  of  the  first  to  look  into  the  matter,  maintained 
that  in  New  York  no  less  than  800  out  of  1,000  husbands  had  suffered  from 
gonorrhea,  and  that  90  per  cent,  of  them  had  not  been  cured.  Their  disease, 
although  it  had  become  latent,  remained  infectious,  and  thus  nearly  all 
married  women  were  infected.^ 

Von  Schaick  ^  undertook  systematic  researches  in  order  to  ascertain  to 
what  extent  married  women  suffering  from  leucorrhea  harboured  gonococci, 
and  found,  amongst  sixty-five  women  examined  in  the  course  of  three  years, 
the  gonococcus  seventeen  times — i.e.,  in  26  per  cent. 

A  striking  example  which  I  had  occasion  to  observe  is  the  following : 

A  young  man  of  twenty-nine  had  had  two  attacks  of  gonorrhea — one  when  he  was 
twenty-one,  and. the  second  one  at  the  age  of  twenty-six.  On  both  occasions  the 
treatment  had  been  insufficient;  but  in  January,  1904,  he  was  free  from  discharge,  as 
he  assured  me.  He,  however,  never  troubled  about  his  water,  as  he  did  not  under- 
stand the  importance  of  the  presence  of  heavy  filaments  in  the  urine,  and  married  with 
a  clear  conscience.  Six  months  after  his  marriage  his  wife  had  a  profuse  white  discharge, 
which  was  treated  with  permanganate  and  silver  nitrate  douches.  At  the  same  time 
he  noticed,  to  his  amazement,  a  big  flow  of  pus  from  his  urethra.  Injections  of  zinc 
sulphate,  and  cubebs  taken  internally  removed  his  discharge  very  quickly,  and  this 
apparent  cure  lasted  about  five  months.  In  the  beginning  of  December,  1904,  the 
running  suddenly  came  on  again,  and  now  his  doctor,  Dr.  Paul  Roger,  sent  him  to  the 
author. 

On  examination  his  discharge  was  found  to  contain  typical  gonococci.  Under 
repeated  irrigations  with  potassium  permanganate  the  discharge  disappeared  rapidly 
and  the  urine  became  clear,  but  some  heavy  filaments  were  still  present  in  the  first 
glass.     Urethroscopy  was  now  resorted  to  (middle  of  January,  1905)  after  previous 

1  Paul  Delbet,  Comptes  Rendus  de  r Association  Frangaise  d'Urologie,  1902,  p.  228. 

2  Noeggerath,  Die  latente  Gonorrhoe,  Bonn,  1872. 

3  Pierre  Delbet,  in  Traite.  de  Chirurgie  de  Duplay-Reclus,  vol.  viii.,  p.  118, 
*  Van  Schaick,  New  York  Medical  Journal,  October  30,  1897,  p.  598. 


16  GONOEKHEA 

dilatation.  It  was  thus  ascertained  that  the  posterior  urethra  was  healthy;  but  the 
penile  urethra  showed  at  the  peno -scrotal  angle  a  patch,  about  2  centimetres  in  length, 
of  typical  infiltrative  lesions.  Methodical  dilatation  with  KoUmann's  straight  dilator 
was  now  resorted  to,  with  the  result  that  this  well-defined  lesion  and  the  heavy  filaments 
disappeared. 

At  the  same  time  I  examined  the  wife,  who  was  eight  months  pregnant,  and  suffered 
from  a  very  free  white  discharge.  Dr.  Rudaux,  who  attended  her,  had  examined  the 
secretions  of  her  urethra,  and  had  found  gonococci.  As  her  pregnancy  did  not  allow 
more  active  measures,  she  was  treated  by  means  of  vaginal  douches  with  permanganate, 
and  local  applications  to  the  outer  surface  of  the  cervix.  A  complete  cure  could  only  be 
effected  after  her  confinement,  when  it  was  permissible  to  treat  the  cavity  of  the  cervix. 

From  the  foregoing  remarks  a  clear  picture  can  be  gained  of  tlie  disasters 
which  a  neglected  urethritis  is  apt  to  cause.  It  is  in  the  interest  of  the 
public  to  point  out  these  facts  to  its  resentment.  There  can  be  no  question 
that  uncured  gonorrhea  is  one  of  the  most  frequent  causes  of  a  declining 
birth-rate,  that  it  cripples  an  endless  number  of  men,  and  that  it  renders 
legions  of  women  sterile. 

Everywhere  in  France  and  abroad  the  statists  dwell  upon  the  danger  of 
a  decline  in  the  birth-rate,  and  the  Boards  of  Health  respond  by  the  call: 
"  Protect  childhood  !"  Would  it  not  be  equally  justified  and  to  the  point 
if  one  proclaimed:  "  Protect  the  future  mothers  "  ? 

The  public  has  not  sufficient  respect  for  gonorrhea;  many  see  in  it  a 
simple  cold  in  the  pipe.  They  treat  it  with  contempt,  and  leave  its  cure 
to  time.  "  Gleet,  that  is  nothing,"  they  say,  and  yet  the  victims  of  neglected 
or  unsuspected  gonorrhea  are  countless  in  both  sexes.  It  is  the  duty  of 
medical  men  to  point  out  these  dangers. 

The  attitude  to  adopt  has  been  well  outlined  by  Dr.  Jullien,  who  says:^ 
"It  is  high  time  that  this  heartbreaking  state  of  afeirs  should  cease.  It 
is  the  duty  of  us  doctors  to  start  a  crusade  against  the  latent  enemy  which 
is  a  hundred  times  more  terrible  than  syphilis,  as  Noeggerath  rightly  claimed. 
Let  us  be  clear  that  we  cannot  point  out  too  often  nor  too  strongly  the  final 
consequences  of  gonorrhea.  Both  the  working  classes  and  the  gentry  should 
understand  how  it  poisons  the  home  and  compromises  the  offspring.  Let 
us  teach  them  the  means  of  recognizing  this  evil;  let  us  keep  them  away 
from  marriage  by  reason,  by  interest;  and,  above  everything,  let  us  learn 
to  cure  them.  This  duty  is  incumbent  upon  us  both  for  the  sake  of  the 
individual  and  for  the  benefit  of  society." 

It  is  not  irrational,  as  has  been  done  lately  in  America,  to  propose  legisla- 
tive measures  which  compel  all  those  who  wish  to  marry  to  submit  to  a 
thorough  medical  examination.^    For  further  information  on  this  subject 

1  Jullien,  Blennorragie  et  Mariage,  Paris  (Bailliere),  1898. 

2  The  State  of  Michigan  considers  all  those  who  attempt  to  marry,  and  are  suffering 
at  the  time  from  gonorrhea  or  syphilis,  as  criminals  liable  to  imprisonment  (up  to  five 
years),  or  to  a  fine  of  $500  to  $1,000  (A.  F.). 


THE  DANGERS  OF  GONORRHEA  17 

the  reader  may  be  referred  to  Paul  Bru's  interesting  study,  Ulnsexuee  ou 
V Autre  Avarie. 

One  should  also  consider  the  unpleasant  position  of  the  medical  man 
in  these  cases.  Thus,  a  patient  may  consult  him,  and  say:  "  Doctor,  I  am 
getting  married  in  a  week,  and  I  cannot  possibly  put  it  off,  as  they  would 
otherwise  break  of!  the  engagement.  I  should  like  your  advice  for  a  little 
trouble  which  I  have,  and  which  I  want  you  to  cure  at  once."  The  examina- 
tion shows  this  fiance  to  be  contagious,  and  his  disease  to  be  of  such  a  char- 
acter that  it  could  not  possibly  be  cured  in  the  short  time  allotted.  The 
doctor  explains  to  him  his  condition  and  its  dangers,  and  informs  him  that 
he  is  on  the  point  of  committing  an  abominable  action  by  contaminating 
deliberately  an  innocent  girl.  However,  he  merely  gets  the  reply:  "I 
would  not  dream  of  giving  up  this  marriage;  it  saves  me  from  ruin.  The 
future  can  look  after  itself."  The  patient  thus  goes  away,  and  commits  his 
crime,  without  there  being  any  means  of  restraining  him. 

Two  conclusions  have  to  be  drawn  from  the  above  remarks:  firstly,  a 
certificate  of  health  and  of  the  completeness  of  the  cure  is  indispensable 
before  entering  upon  wedlock,  and,  secondly,  the  young  men  should  be 
informed  of  the  perils  which  await  them.  Not  only  should  the  necessary 
instruction  be  given  in  the  upper  forms  at  school,  but  also  in  the  barracks 
and  at  home.     They  will  then  be  in  a  better  position  to  avoid  the  danger. 

The  Social  Struggle  against  Gonorrhea. 

We  have  seen  above  the  dangers  with  which  gonorrhea  threatens  both 
the  individual  and  society. 

With  reference  to  the  campaign  against  this  evil,  two  important  factors 
deserve  attention:  firstly,  the  ignorance  of  the  danger  prevailing  amongst 
young  people,  and,  secondly,  excessive  confidence. 

Amongst  the  victims  of  ignorance  we  find  firstly  the  sons  who  grew  up  in 
the  bosom  of  their  family,  and  know  nothing  about  sexual  life.  The  others, 
who  have  been  to  a  public  school,  are  usually  full  of  wrong  ideas,  as  it  is 
extremely  difficult  to  give  proper  instruction  on  this  subject,  which  most 
masters  and  principals  are  loath  to  discuss. 

In  the  barracks  conditions  are  better.  In  France  special  lectures  are 
given  in  the  various  regiments  in  order  to  warn  the  soldiers  against  the 
dangers  of  venereal  diseases. 

Very  generally,  the  young  man  who  has  just  acquired  his  first  attack  of 
gonorrhea  has  but  vague  notions  of  his  disease.  He  may  have  heard  of 
violent  pains  "  like  a  razor,"  but  he  seldom  thinks  of  the  possibility  of  having 
been  infected ;  and  once  he  realizes  what  has  happened,  he  is  usually  hope- 
lessly helpless.    Instead  of  going  to  a  medical  man,  who  would  attend  to  his 

2 


18  GONORRHEA 

illness  properly,  and  confirm  the  diagnosis  by  microscopy,  he  runs  to  the 
first  chemist.  Any  drug  warmly  recommended  is  readily  accepted,  or  else 
the  choice  is  guided  by  advertisements  seen  in  the  daily  papers  or  by  a  kind 
friend. 

This  state  of  affairs  is  largely  due  to  the  deplorable  fallacy  that  gonor- 
rhea is  but  a  trifling  ailment. 

Excessive  confidence  is  another  cardinal  factor  in  the  dissemination  of 
the  illness.  Many  men  of  sufficient  knowledge  and  experience,  who  have  a 
good  general  notion  of  venereal  diseases  and  of  their  mode  of  dissemination, 
neglect  the  most  elementary  precautions  at  the  right  moment. 

The  woman  is  quite  healthy,  they  say,  when  they  consult  their  doctor. 
But  what  do  they  know  about  it  ?  Even  a  medical  certificate  is  no  guarantee. 
After  having  acquired  gonorrhea,  a  woman  has  obviously  a  few  symptoms ; 
but  they  soon  pass  off,  and  the  late  effects  are  often  so  insignificant  that  she 
becomes  convinced  of  her  recovery,  and  manages  to  persuade  her  surround- 
ings, including  her  doctor,  to  that  effect. 

In  fact,  often  these  women  who  appear  to  be  cured  are  still  contagious ; 
their  virulence  is  dormant,  but  it  regains  its  full  power  now  and  then,  when 
circumstances  are  favourable,  such  as  the  periods,  a  strong  orgasm,  and 
temporary  lack  of  cleanliness  about  the  genitals. 

We  have  frequently  come  across  cases  in  which  young  men  acquired 
gonorrhea  after  several  months'  cohabitation,  both  parties  being  faithful  to 
each  other. 

An  interesting  example  has  been  published  by  Dr.  Carle  of  Lyons,  which 
may  be  quoted:^  "  A  young  man  had  attached  himself  to  a  little  lady  who 
once  had  suffered  from  gonorrhea,  but  had  given  up  her  former  life,  and  he 
enjoyed  two  years  of  uninterrupted  happiness  with  her.  One  day,  as  the 
couple  were  on  a  cycle  tour  in  the  Alps,  the  solitude  and  the  bracing  air 
revived  their  evil  desires,  which  they  satisfied  on  the  spot,  surrounded  by 
magnificent  scenery.  There  being  no  water  near,  all  washings  had  to  be 
omitted,  and  six  days  later  the  young  man  had  a  typical  discharge." 

On  other  occasions  the  patients  say  that  "  they  cannot  have  the  clap, 
because  their  sweethearts  are  true  to  them,  or  because  their  mistress  is 
a  married  woman,  or  because  they  have  been  to  a  brothel." 

It  is  obvious  that  the  faith  which  underlies  these  statements  is  totally 
ill-founded. 

The  Legal  Aspect  of  Gonorrhea. 

As  the  subject  of  this  paragraph  is  beyond  the  province  of  medicine, 
I  have  sought  the  advice  of  some  of  the  most  distinguished  members  of  the 
Bar  in  Paris.    Men  like  Henry  Aubepin,  Duhil,  Touret-Pialat,  and  others, 

1  M.  Carle,  La  Blennorragie  Uretrale  (0.  Doin),  1910,  p.  12. 


THE  DANGERS  OF  GONOERHEA  19 

have  kindly  supplied  me  with  valuable  and  interesting  matter  for  this 
paragraph,  for  which  I  wish  to  tender  them  my  best  thanks. 

Although  legal  proceedings  against  a  person  who  infects  a  healthy 
person  with  gonorrhea  are  just,  and  appeal  forcibly  to  the  mind  of  the 
public,  yet  there  is  no  special  law  to  that  effect,  and  those  in  force  leave  a 
number  of  loopholes  which  allow  the  culprit  to  escape  prosecution. 

In  French  law  it  is  generally  admitted  as  a  point  of  law  that  the  trans- 
mission of  venereal  disease  by  one  consort  to  the  other  does  not  necessarily 
and  of  itself  constitute  a  ground  for  divorce  or  separation.  It  only  becomes 
such  if  it  is  accompanied  by  accessory  facts  and  circumstances  which  give 
it  the  character  of  "  cruelty."^ 

Such  "  cruelty  "  is  present  if  the  contaminating  party  did  so  knowingly 
— i.e.,  if  he  (or  she)  knew  at  the  time  that  he  (or  she)  was  suffering  from  a 
venereal  disease.  "  The  fact  of  having  knowingly  exposed  his  wife  (or  her 
husband)  to  the  dangers  of  contamination  .  .  .  implies  undoubtedly,  if  it  can 
be  proved,  cruelty,  and  is  therefore  a  ground  for  an  application  for  divorce."  ^ 

Thus,  all  depends  on  this  point:  the  guilty  party  is  only  punishable  if 
he  (or  she)  contaminated  the  other  party  knowingly. 

If  a  husband  infects  his  wife  with  gonorrhea,  and  if  it  can  be  proved  that 
he  knew  that  he  was  ill,  and  that  he  exposed  her  to  infection  despite  this 
knowledge,  then  he  has  committed  an  act  of  gross  cruelty.  His  wife  could 
under  these  conditions  not  be  compelled  to  live  with  him  again,  as  she  could 
not  have  any  other  feelings  towards  him  than  amply  justified  aversion  and 
profound  contempt.^ 

The  Gazette  des  Tribunaux  of  October  6,  1897,  states  definitely:"*  "A 
wife  has  no  right  to  demand  a  divorce  because  her  husband  gave  her  a 
venereal  disease,  unless  it  be  proved  that  she  was  infected  knowingly  by 
her  husband." 

If  the  contamination  took  place  unknowingly — if  the  infecting  party 
was  unaware  of  his  illness,  or  believed  himself  to  be  cured — then  neither 
divorce  nor  separation  can  be  granted.'^ 

The  contamination  itself  is  thus  of  little  importance  compared  with 
the  intention.  "  The  mere  fact  of  a  husband  having  infected  his  wife  with 
a  venereal  disease  is  not  a  sufficiently  serious  cruelty  to  justify  an  applica- 
tion for  divorce  or  separation,  providing  he  had  reason  to  believe  himseli 
cured,  and  providing  he  thus  did  not  consider  himself  any  longer  con- 
tagious "  (Nancy,  January  26,  1901). 

1  Courts  :  Toulouse,  January  30,  1821  ;  Rennes,  July  14,  1866  (D.  68.2.163);  Paris, 
April  13, 1897  (D.  97.2.137);  Aubry  and  Rau;  Demolonde,  t.  4.,  No.  389. 

2  Courts :  Vouziers,  July  18,  1907,  Gaz.  du  Pal,  September  24,  1907. 

3  Courts:  Lille,  December  15,  1898. 
*  Courts :  Seine,  June  4,  1897. 

5  Courts :  St.  Quentin,  January  24,  1907  {Gaz.  du  Pal.,  May  4,  1907). 


20  aONORRHEA 

The  court  in  Douai  (January  7,  1908),  and  the  Droit  (April  11,  1908), 
have  developed  this  view  further:  "  The  fact  that  a  husband,  when  informed 
by  a  medical  prescription  of  his  wife's  illness,  shows  no  surprise,  continues 
to  live  with  her,  casts  no  doubts  upon  her  moral  conduct,  and  fails  to  bring 
a  counter-action  when  divorce  proceedings  are  pending  against  him,  may 
be  interpreted  as  a  tacit  admission  of  his  guilt,  as  far  as  the  contamination 
which  he  was  accused  of  is  concerned." 

The  infected  wife  must  be  treated  as  soon  as  possible.  This  duty  has 
been  clearly  established  by  the  Bordeaux.  Courts :  "  A  husband  who  has  given 
his  wife  a  venereal  disease,  be  it  even  without  his  knowledge,  is  guilty  of  a 
cruelty  which  would  be  a  suflB.cient  ground  for  separation,  if  he  sacrificed 
his  wife's  health  to  a  false  sense  of  shame,  and  failed  to  take  the  promptest 
measures  to  check  the  havoc  of  the  malady  "  (Bordeaux,  February  18,  1857). 

Translator's  Note. — -As  the  legal  position  of  those  who  infect  others  with  gonorrhea 
is  somewhat  different  in  England,  a  few  notes  for  which  I  am  indebted  to  Mr.  H.  Morse 
Hewitt  may  here  find  room. 

Generally  speaking,  if  a  man  infects  a  woman,  or  vice  versa,  with  gonorrhea,  the 
infected  party  has  no  legal  remedy  in  damages,  or  otherwise,  against  the  infecting  party. 
In  the  case  of  husband  and  wife,  there  are,  however,  statutory  enactments  which 
have  to  be  considered. 

One  should  imagine  that  the  communication  of  gonorrhea  from  one  consort  to  the 
other  would  be  in  itself  sufficient  evidence  of  adultery  having  been  committed  by  the 
infecting  party.  But  this  is  not  so.  The  law-courts  hold  that  gonorrhea  (or  any  other 
venereal  disease)  is  uncertain  evidence;  for,  regarded  strictly,  such  disease  would  be 
consistent  with  the  adultery  of  either  party,  and,  moreover,  it  would  also  be  consistent 
with  accidental,  non-venereal  transmission  of  the  disease. 

It  is  therefore  always  necessary  to  bring  special  proof,  supported  by  other  facts, 
that  adultery  has  been  committed,  if  one  wishes  to  obtain  a  divorce  or  a  judicial  separa- 
tion, as  the  case  may  be.  Proof  of  adultery  alone  would  suffice  in  the  case  of  the 
husband's  suit  to  obtain  his  divorce. 

In  the  case  of  the  wife's  suit,  both  adultery  and  "legal  cruelty" — of  which  there 
are  many  kinds,  the  communication  of  a  venereal  disease  being  only  one  variety — 
have  to  be  proved,  unless,  and  until,  the  present  laws  be  altered,  as  recommended  by 
the  Majority  Report  of  the  Royal  Commission. 

In  order  to  prove  "legal  cruelty"  by  the  communication  of  gonorrhea,  this  com- 
munication must  be  shown  to  have  been  wilful. 

If  a  married  man  infects  his  wife  wilfully  with  gonorrhea  (or  any  other  venereal 
disease),  or  vice  versa,  without  additional  marital  offence,  the  injured  party  is  only 
entitled  to  apply  for  a  judicial  separation,  for  the  reason  already  mentioned,  that  the 
communication  of  a  venereal  disease  is  no  proof  of  adultery. 

The  courts  of  law  cannot  compel  the  guilty  husband  to  have  his  wife  treated  and 
cured  of  the  illness  he  gave  her.  But  she  may  seek  treatment  of  her  own  accord,  and 
at  her  husband's  expense ;  for  the  medical  man  in  attendance  would  be  entitled  to  recover 
his  fees  directly  from  the  husband,  on  the  ground  that  his  advice  and  attendance  come 
under  the  designation  of  "  necessaries  "  for  which  a  husband  is  responsible. 

In  the  United  States  there  is  no  uniform  legislation  concerning  divorce  and  com- 
munication of  a  venereal  disease.  Each  State  has  its  own  laws,  and  hence  it  is  impossible 
to  discuss  this  subject  here. 


CHAPTEE  III 

THE  ETIOLOGY  OF  GONORRHEA 

Inflammation  of  the  urethral  mucous  membrcme  which  shows  itself  by  a 
discharge  is  always  caused  by  some  irritant  which  acts  wpon  it. 

In  1782  Swediaur  proved  experimentally  tliat  urethral  inflammation 
can  be  produced  by  tlie  injection  of  irritating  chemicals.  He  injected 
ammonia  into  bis  own  urethra,  with  the  result  that  he  developed  a  violent 
urethritis,  which  in  its  course  and  in  its  clinical  symptoms  closely  imitated 
a  typical  attack  of  acute  gonorrhea. 

Later,  Cullerier  and  others  took  up  these  experiments,  and  obtained 
similar  results. 

It  is  nowadays  well  known,  thanks  to  Neisser's  discovery  of  the  gono- 
coccus  in  1879,  that  the  most  frequent  cause  of  gonorrhea  is  a  specific 
organism — namely,  Neisser's  gonococcus. 

One  should,  however,  not  forget  that  there  are  a  number  of  other 
organisms  capable  of  producing  urethral  discharges,  and  that  this  type  of 
urethritis  is  very  common.  We  will  consider  them  later  {vide  Chapter  IV.), 
and  devote  our  attention  at  present  to  the  gonococcus. 

The  Gonococcus. 

This  organism  was  discovered  by  Neisser  in  the  year  1879  in  discharges 
from  the  urethra.  It  is  the  best-known  specific  cause  of  gonorrhea,  and  is 
never  found  as  a  saprophyte  in  healthy  organs. 

Frequency. — Gronorrhea  is  a  very  common  complaint,  so  much  so  that 
but  few  men  reach  their  prime  without  having  had  it  once,  or  more  often. 
It  is  only  contracted  in  one  way — namely,  by  contagion. 

Ways  in  which  the  Contagion  is  brought  about. — The  infection  of  the 
urethra  by  the  gonococcus  during  coitus  may  take  place  in  various  ways. 

Those,  for  instance,  who  are  slow  run  great  risks,  and,  as  Baumes  tells 
us,  also  those  who,  without  erection  or  connection,  allow  the  tip  of  their 
penis  to  touch  the  external  genitals  or  the  inner  surface  of  the  upper  part  of 
the  thighs  of  the  woman,  for  these  structures  are  only  too  often  soiled  with 
gonococcal  material. 

Indirect  contagion  from  one  man,  who  has  the  disease,  to   another, 

21 


22  GONOKRHEA 

through  a  vagina  which  has  escaped  infection,  is  also  possible.  Diday  ^  has 
mentioned  such  a  case:  On  an  excursion,  six  young  men  had  successively 
intercourse  with  the  same  woman,  who  was  stated  to  be  healthy.  The  first 
actor  of  this  scene  had  an  inveterate  attack  of  gonorrheal  folliculitis.  His 
immediate  successor  was  the  only  one  to  be  infected.  Diday  follows  from 
this  that  "  he  had  been  infected  by  the  fluid  of  the  follicle  deposited  in  the 
vagina  of  the  woman  an  instant  previously." 

Such  indirect  contamination  is  also  possible  if  the  gonococcus  has  been 

recently  deposited  on  a  mucous  surface  which  is  an  unsuitable  medium  for 

'  its  growth,  providing  the  urinary  meatus  comes  into  contact  with  this 

surface.     This  is  the  mechanism  of  certain  infections  per  os  (vide  Gonorrhea 

Buccalis,  Chapter  IX.). 

Gonorrheal  urethritis  in  man  is  thus  always  derived  from  a  gonococcal 
infection  present  in  the  contaminating  woman  at  the  time  of  intercourse. 
It  must,  however,  be  conceded  that  certain  adjuvant  factors,  which  are 
well  summed  up  in  Kicord's  famous  recipe  for  getting  the  clap,  are  some- 
times necessary. 

"  Do  you  wish  to  get  the  clap  ?"  he  used  to  say.  "  This  is  the  way  to 
do  it:  Take  a  lymphatic,  pale,  and  preferably  blond  woman  who  suffers 
from  as  profuse  a  whitish  discharge  as  you  can  find.  Dine  with  her;  begin 
with  oysters,  continue  with  asparagus,  drink  heavily  white  wine,  cham- 
pagne, and  liqueurs.  You  will  be  well  on  the  way  then.  To  expedite 
matters,  dance  together  after  dinner  till  you  get  hot.  Then  take  plenty  of 
beer,  and,  once  the  night  has  come  on,  set  to  work  energetically;  two  or 
three  connections  are  by  no  means  too  much — the  more  the  better.  Next 
morning  remain  in  a  hot  bath  for  some  time,  and  take  a  urethral  injection. 
If  you  live  up  to  this  programme,  and  do  not  get  ill,  you  must  be  under  the 
special  protection  of  a  god." 

Excitement  is  thus  an  important  predisposing  factor.  Amongst  the 
various  conditions  which  favour  infection,  abuse  of  spicy  dishes,  of  drinks 
and  of  champagne,  sexual  excess,  and  prolonged  connections,  especially  in  a 
state  of  inebriety,  deserve  special  mention. 

The  lazy  or  "  refined  "  intercourses,  as  well  as  those  to  which  there  is 
no  end,  are  the  most  dangerous,  and  are  most  often  followed  by  infection. 
"  Oportet  non  morari  in  coitu,"  said  Nicolas  Massa  :  "  Wise  lovers  are  quick." 

Further  congestive  phenomena  which  favour  infection  are  those  which 
precede,  accompany,  or  follow  upon  menstruation  and  pregnancy.  Latent 
gonococcal  infections  tend  to  flare  up  under  their  influence,  and  to  become 
virulent  again. 

This  phenomenon  explains  certain  observations,  such  as  the  following: 
A  woman  yields  successively  to  several  men,  and  only  contaminates  one, 

^  Diday,  Gazette  Hebdom.  de  Medecine  et  de  Chirurgie,  1860,  p.  727. 


THE  ETIOLOGY  OF  GONORRHEA  23 

whilst  tlie  others  remain  unaffected.  It  seems  a  fact  that  a  man  with  whom 
the  intercourse  is  "  indifferent  "  does  not  elicit  the  particular  secretion 
which  accompanies  the  orgasm  in  woman,  and  that  he  thus  has  a  much 
better  chance  of  escaping  infection  than  the  man  who  "  pleases,"  and  causes 
a  copious  secretion  during  the  height  of  pleasure.  This  profuse  flow  empties 
the  infected  glands,  mobilizes  the  gonoccoci,  and  brings  them  into  contact 
with  the  male  urethra. 

How  often  do  we  not  hear  patients  say,  who  come  to  us  after  they  have 
acquired  gonorrhea :  "  Doctor,  I  have  a  slight  discharge,  but  I  am  certain 
that  the  woman  from  whom  I  got  it  has  not  got  the  clap  "  !  Such  statements 
should  be  received  with  suspicion,  once  the  microscope  has  revealed  the 
presence  of  Neisser's  organism ;  and  even  if  the  examination  of  the  woman 
fails  to  show  any  gonococci — a  rare  occurrence — one  should  suspect  her, 
unless  other  sources  of  infection  are  probable  {vide  Chapter  VII.). 

Others,  again,  still  more  reckless,  say :  "  I  know  for  certain  that  my  sweet- 
heart has  no  disease.  She  is  the  wife,  or  the  mistress,  as  the  case  may  be,  of 
my  best  friend,  and  there  is  nothing  wrong  with  him."  This,  again,  is  a 
mistaken  theory,  which  finds  its  explanation  in  the  facts  mentioned  above. 

Herewith  a  case  in  point :  A  youth  suffering  from  gonorrhea  assured  me 
that  his  mistress,  the  wife  of  his  best  friend,  could  not  be  ill,  because  her 
husband  was  free  from  disease.  I  went  into  the  matter,  and  discovered  the 
following  characteristic  facts :  The  woman  was  "  indifferent "  to  her  husband, 
and  only  had  intercourse  with  him  after  careful  douching,  and  she  also 
used  the  douche  afterwards.  Her  relations  with  my  patient  were,  however, 
not  "  indifferent,"  and  the  two  were  in  the  habit  of  satisfying  their  desires 
hastily,  irregularly,  and  without  taking  any  precautions. 

This  mechanism  is  typical  for  a  good  number  of  infections. 

The  following  story  may  also  serve  as  example  to  show  how  little  im- 
portance is  to  be  attached  to  the  statements  of  certain  women  : 

In  September,  1909,  a  young  man  consulted  me  for  a  discharge  which 
contained,  as  the  microscope  showed,  a  great  number  of  typical  gonococci. 
He  was  very  astonished,  and  assured  me  that  his  sweetheart,  to  whom  he 
had  always  been  true,  could  not  be  ill,  because  she  had  only  recently  been 
examined  by  a  doctor,  who  had  certified  her  as  having  no  lesions  about  her 
generative  organs.  I  thereupon  asked  to  be  allowed  to  examine  the  lady, 
and  she  consented.  The  most  careful  search  failed  to  reveal  any  lesion 
about  the  urethra,  vagina,  cervix,  and  Bartholin's  glands,  and  I  was  on 
the  point  of  sending  her  away,  when  I  once  more  cross-questioned  her.  I 
now  managed  to  extract  the  following  information :  Under  normal  conditions 
their  relations  had  never  given  rise  to  any  trouble.  But  once,  during  his 
mihtary  service,  cohabitation  a  ^posteriori  had  taken  place,  in  order  to 
avoid  the  douching,  which  would  have  been  very  inconvenient  at  the  time. 


24  GONORKHEA 

In  former  days  site  had.  had.  another  lover,  who  suffered  from  gleet,  and  was 
addicted  to  this  nnnatural  practice.  The  case  was  thus  explained ;  and  when 
I  examined  her  rectum  with  my  rectoscope  a  few  days  later,  I  found  a 
markedly  inflamed,  easily  bleeding  mucous  membrane — ^typical  proctitis. 

As  Finger^  has  pointed  out,  a  slightly  alkaline  medium  is  most  suitable 
for  the  development  of  micro-organisms,  and  in  particular  of  the  gono- 
coccus.  Under  ordinary  circumstances  the  urethral  mucous  membrane  is 
bathed  in  an  acid  medium,  owing  to  the  few  drops  of  urine  which  are  left 
behind  after  micturition.  This  slight  acidity,  which  is  already  sufl&cient  to 
compromise  the  vitality  of  the  spermatozoa,  is  neutralized  by  the  urethral 
glands,  which  begin  to  secrete  when  erection  takes  place.  The  clear, 
viscous,  alkaline  secretion  of  these  glands,  however,  not  only  favours  the 
vitality  of  the  spermatozoa,  but  also  renders  the  urethral  mucosa  more  apt 
to  be  infected  by  the  gonococcus. 

As  conditions  which  are  unfavourable  to  infection  may  be  mentioned :  con- 
nection of  short  duration,  single  coitus,  and  immediate  micturition  after  the 
act.  The  urethra  thus  becomes  acid  again  almost  at  once,  and  is  freed  as  far 
as  possible  from  any  gonococci  which  may  be  present.  This  practice  is,  by  the 
way,  well  known  under  the  somewhat  vulgar  term  of  "  I'injection  du  zuave." 

Lastly,  the  question  of  constant  recurrences  of  gonorrheal  urethritis 
deserves  attention.  Formerly  some  doubts  existed  as  to  their  production,  but 
nowadays  only  two  causes  can  be  admitted  for  these  constant  reinfections 
of  the  urethra : 

1.  Auto-reinoculation  of  the  urethra  from  a  focus  which  has  not  been 
cured  (littritis,  cowperitis,  prostatitis,  vesiculitis,  etc.). 

2.  Hetero-inoculation  from  a  fresh,  unknown  woman,  or  from  one's 
habitual  consort  (wife  or  mistress),  who  has  been  previously  contaminated, 
and  now  returns  her  lover's  or  her  husband's  gift  with  interest. 

In  cases  of  this  latter  type,  the  disease  is  usually  most  inveterate,  and 
a  cure  is  only  possible  if  both  parties  allow  themselves  to  be  disinfected 
simultaneously. 

Contamination  through  Inert  Objects. — Gonorrhea  can  be  transmitted 
by  soiled  towels,  by  water  which  has  just  been  used,  etc. 

Benajmin  Bell  quoted  the  case  of  two  students  who  had  never  had  gonor- 
rhea, and  who  conceived  the  brilliant  idea  of  placing  a  piece  of  gauze 
impregnated  with  gonorrheal  pus  between  their  glans  and  prepuce  for 
twenty-four  hours.  Both  acquired  a  balanoposthitis,  and  one  of  them  an 
acute  urethritis  as  well,  which  lasted  for  more  than  a  year. 

The  vulvo- vaginitis  of  little  girls  is  often  due  to  contact  with  towels, 
sheets,  or  sponges,  which  have  been  soiled  by  the  diseased  organs  of  others 
(parents,  etc.). 

1  Finger,  in  his  textbook  on  Gonorrhea  and  its  Complications. 


THE  ETIOLOGY  OF  GONOEHHEA  25 

Guiard  observed  a  case  in  which  a  lady  was  infected  through  the  nozzle 
of  her  own  douche,  which  had  been  used  in  her  absence,  and  without  her 
knowledge,  by  her  maid,  who  was  suffering  from  gonorrhea. 

Effect  of  Age. — There  is  little  doubt  that  age  has  a  certain  influence 
upon  the  course  of  gonorrhea.  The  old  man  who  gets  the  clap  is  seriously 
exposed  to  complications,  especiall}^  to  a  rapid  ascending  infection, 
involving  his  bladder  and  his  kidneys.  "  If  the  pox  does  not  care  for  old 
men,  the  clap  is  also  hard  on  them  "  (Ricord). 

Gonorrhea  Vulvitis  in  Little  Girls. — Little  girls  frequently  contract 
vulvitis,  and  one  of  the  causes  of  their  malady  is  the  custom  of  taking  them 
into  the  bed  of  their  parents,  which  is  often  soiled  with  gonorrheal  discharge. 

Very  generally  these  children  are  badly  looked  after,  and  it  is  not  rare 
to  find  much  later  in  life  innocent  girls  suffering  from  rebellious  chronic  dis- 
charges which  contain  the  gonococcus,  and  thus  reveal  their  origin,  which 
lies  far  back.  A  case  of  this  kind  which  has  come  under  my  personal 
observation  is  the  following: 

In  October,  1909,  Professor  Pozzi  sent  me  a  man  of  thirty-six  who  was  in  a  state  of 
despair.  He  had  contracted  gonorrhea  when  nineteen,  had  been  insufficiently  treated, 
and  had  never  got  rid  of  his  disease.  He  believed,  however,  that  the  virulence  ought  to 
have  subsided  after  a  number  of  years,  and  thus  he  married  at  the  age  of  twenty-six. 
Shortly  afterwards  his  wife  became  ill,  and  she  was  put  under  the  care  of  Professor 
Pozzi,  who  first  curetted  her,  and  later  found  it  necessary  to  remove  the  uterus  and  its 
appendages  by  the  abdominal  route.  This,  however,  was  only  part  of  the  disaster. 
Their  issue,  a  little  girl,  acquired  gonorrheal  vulvo- vaginitis  at  the  age  of  eight  by  being 
taken  into  her  parents'  bed,  the  sheets  of  which  were  soiled  with  gonococcal  pus. 

On  examination,  the  man  was  found  to  be  suffering  from  a  chronic  inflammation  of 
Littre's  glands,  which  had  been  in  this  condition  for  nineteen  years,  and  which  were 
certainly  responsible  for  the  illness  of  his  wife  and  of  his  child  ! 

On  being  acquainted  with  this  truth,  the  unfortunate  husband  was  in  a  state  of 
frenzy,  but  the  damage  was  done. 

Influence  of  Fever. — An  intercurrent  fever  has  a  marked  effect  upon 
urethral  discharges.  Vidal  de  Cassis  had  already  noted  that  discharges 
cease  during  attacks  of  rheumatism,  and  reappear  when  the  joint  trouble 
subsides.  Bogdan^  quotes  a  case  in  which  the  gonorrheal  discharge  dis- 
appeared in  pneumonia,  and  returned  once  the  lungs  were  normal  again. 
Guiard  observed  a  young  man  who  developed  scarlet  fever  whilst  he  was 
suffering  from  a  rebellious  chronic  urethritis;  in  this  case  the  discharge 
disappeared  during  the  fever,  and  remained  cured. 

It  is  a  matter  of  common  knowledge  that  in  cases  of  epididjnuo-orchitis 
which  are  accompanied  by  high  fever  the  discharge  diminishes,  or  even 
disappears  for  the  time  being. 

I  have  seen  a  young  man  who  developed  mumps  whilst  suffering  from 

1  Bogdan,  Annates  de  Dermatologie,  1893,  p.  253. 


26  GONORRHEA 

gonorrhea.  His  temperature  was  very  high  (40°  C.  =  104°  F.),  and  with 
the  fever  the  discharge  disappeared  completely.  But  once  the  intercurrent 
illness  had  left  him,  the  flow  came  on  again,  and  had  to  be  treated  in  the 
U3ual  way.  This  coincidence  of  fever  and  improvement  induced  me  to 
make  use  of  heat  therapeutically,  and  for  a  time  I  hoped  to  obtain  a  rapid 
general  destruction  of  the  gonococci  by  heat  (vide  Chapter  XII.). 

But  if  the  discharge  diminishes  or  disappears  for  a  time,  whilst  an  inter- 
current illness  produces  high  fever  (up  to  104°  F.),  it  yet  remains  true  that 
the  gonococcus  resists  for  a  considerable  time. 

Nobl^  has  published  five  cases  of  gonorrhea,  complicated  by  various  febrile 
affections  (pneumonia,  pulmonary  tuberculosis),  in  which  the  gonococcus 
was  in  no  way  influenced,  as  far  as  its  virulence  and  resisting  powers  were 
concerned,  although  there  was  prolonged  high  fever  of  104°  F. 

On  the  other  hand,  Nogues  has  published  two  cases  of  gonorrhea  in 
which  high  fever  led  to  a  spontaneous  cure.^ 

The  gonococcus  can  remain  in  the  latent  state  for  a  very  long  time 
within  the  urethral  mucous  membrane.  It  is  not  rare  to  find  patients  who 
have  had  no  trace  of  moisture  about  their  urethra  suddenly  develop  some 
local  or  general  complication  caused  by  the  gonococcus. 


The  Morphology  of  the  Gonococcus. 

A  knowledge  of  the  gonococcus  is  indispensable  for  the  clinical  appre- 
ciation of  gonorrhea.  The  characteristic  and  pathognomonic  features  which 
are  essential  are  the  following  : 

Shape. — The  gonococcus^  is  not,  as  its  name  would  indicate,  a  true  coccus. 
Its  outlines  are  not  round,  and  it  is  always  found  in  the  diplococcus  form, 
consisting  of  two  parts   of   ovoid  shape  which   are 
darker  than  the  background,  and  are  separated  by  a 
light  line.     Each  member  has  the  shape  of  a  cofiee  bean 


CI 


^tk  or  of  a  French  bean;  the  straight  or  concave  surfaces 

^ft  ^^       are  in  apposition  (Enschbaum's  notch).     The  organism 

^      „     ^  is  1  tt  long,  and  0-6  to  0-7  a  wide. 

Fig.  3. — Gonococci  mi  ■  ^ 

(diagrammatic).  Grouping. — The  gonococci  are  always  present  m 

(After  J.  Courmont.)     clusters  and  in  clumps,  but  they  never  form  chains. 

The  two-and-two  arrangement  is  always  present. 

Movements. — These  movements  are  not  easily  seen,  as  they  are  only  visible 

in  unstained  preparations.     One  has,  however,  noted  a  slow   oscillatory 

^  Nobl,  "  Klinischer  Beitrag  zur  Biologie  der  Gonokkoken,"  Wiener  Klin.  Rund- 
schau, 1901,  Nos.  46  and  47. 

2  Annates  Oenito-Urinaires,  1907,  p.  1288. 

3  V.  Marcel.  See  Le  Gonocoque,  (Thesis,  Paris,  1896). 


THE  ETIOLOGY  OF  GONORRHEA  27 

translation  movement  and  a  rotatory  movement,  one  of  the  two  members 
of  a  diplococcus  being  on  top  of  tbe  other  alternately. 

Lately  Dr.  Comandon,  who  has  applied  with  such  success  the  cinemato- 
graph to  the  study  of  the  movements  of  microbes,  has  investigated  those  of 
the  gonococcus,  and  found  the  translation  movement  to  be  limited.  This 
organism  is  sluggish,  and  its  movements  are,  in  his  opinion,  simply  Brownian. 
Its  colonies  only  advance  by  their  development  and  their  increase  in  size. 
It  therefore  requires  a  considerable  time  for  Neisser's  coccus  to  reach  the 
posterior  urethra  by  its  own  means.  This  interesting  fact  is  of  capital 
importance:  it  shows  the  dangers  of  clumsy  injections — how  they  dislodge 
the  gonococcus  from  its  original  focus,  and  carry  it  to  distant  parts. 

Staining  Properties. — The  organism  is  readily  stained  by  the  aniline 
dyes,  especially  methylene-blue;  it  is  Gram-negative,  being  easily  decolorized 
by  this  method. 

Technique  of  Searching  for  Gonococci — Examination  of  the  Discharge. — 
The  simplest  method  is  the  following :  By  means  of  a  platinum  loop  which 
has  been  passed  through  the  flame  and  allowed  to  cool,  a  bead  of  pus  is  taken 
from  the  meatus,  which  has  been  previously  cleansed  with  a  piece  of  wool 


Fig.  4. — Mounted  Platinum  Loop  for  collecting  the  Dischaege  from  the 

Meatus. 

soaked  in  boric  lotion.  This  bead  of  pus  is  gently  squeezed  out  of  the 
urethra;  this  precaution  is  of  importance,  because  brutal  squeezing  is  apt 
to  injure  the  urethral  glands.  This  "  milking  "  should  not  only  involve  the 
tip  of  the  penis,  but  the  entire  anterior  urethra,  starting  at  the  perineum  and 
scrotum,  and  working  gradually  forwards. 

The  bead  of  pus  is  then  spread  out  by  means  of  the  loop,  or  of  an  ordinary 
steel  needle,  on  the  surface  of  a  slide  to  form  a  thin  and  even  layer,  and 
allowed  to  dry.  This  is  the  most  satisfactory  way;  compression  of  the 
discharge  between  two  slides  often  gives  bad  preparations. 

The  smear  is  then  fixed  by  passing  it  three  times  through  a  spirit  or 
Bunsen  flame,  and  is  ready  for  staining. 

Microscopic  Examination  of  the  Filaments. — The  fllaments  contained  in 
the  urine  should  also  be  examined  bacteriologically.  For  this  purpose,  the 
patient  is  asked  to  make  water  into  a  glass,  from  which  one  tries  to  recover 
the  filaments.  This  fishing  is  often  tedious  and  troublesome,  but  one 
finally  manages  to  seize  them  with  forceps  or  to  roll  them  on  to  the  platinum 
wire.  They  are  then  spread  out  on  a  slide.  Owing  to  their  viscous  nature, 
they  are  not  easily  fixed,  and  tend  to  slip  off.  By  passing  a  current  of  air 
over  them  this  process  can  be  much  faciUtated. 


28  GONOKEHEA 

These  filaments  are  stained  in  the  same  way  as  the  discharge. 
Staining. — Kiihne's  carbol-methylene-blue  gives  the  best  results,  and 
has  the  following  formula: 

Absolute  alcohol  . .  .  .  .  .  .  .      10  c.c. 

Methylene -blue  . .  . .  . .  . .     1-5  grammes. 

Dissolve,  and  add  after  twenty-four  hours  : 
5  per  cent,  solution  of  carbolic  acid        . .  . .     100  c.c. 

The  stain  is  allowed  to  act  for  a  few  minutes,  and  is  then  washed  o&  in 
running  water.  The  slide  is  now  dried  and  ready  for  examination.  The 
whole  process  takes  takes  less  than  five  minutes. 

Nicolle's  Method  for  staining  Gonococci. — Another  method  for  staining 
gonococci  has  been  devised  by  Nicolle:^  The  pus  is  spread  out  on  a  slide, 
and  rapidly  dried  by  passing  it  through  the  flame  of  a  lamp.  The  smear 
is  then  deprived  of  its  fat  by  dipping  it  for  a  few  seconds  in  a  mixture  of 
equal  parts  of  90  per  cent,  alcohol  and  sulphuric  ether.  It  is  then  dried  in 
the  air,  and  a  few  drops  of  carbol-thionin  are  poured  on  to  the  slide. 

After  a  minute  the  slide  is  stained ;  the  excess  of  colouring  matter  being 
washed  of!  in  running  water,  the  preparation  is  dried  and  put  under  the 
microscope. 

The  carbol-thionin  solution  used  has  the  following  formula : 

Saturated  solution  of  thionin  in  50  per  cent,  alcohol  10  c.c. 

1  per  cent,  solution  of  carbolic  acid  . .  . .     100    ,, 

Or  one  may  use  the  following  process  :^  The  dried  slide  is  stained  with 
a  few  drops  of  the  following  solution : 

Thionin  solution  .  .  . .  .  .  . .       10  c.c. 

Distilled  water  .  .  .  .  .  .  .  .       88     ,, 

Liquid  phenol  . .  . .  . .  . .         2     ,, 

washed  with  water,  and  treated  for  a  minute  with  a  mixture  consisting  of — 

Saturated  aqueous  solution  of  picric  acid  . .  . .       60  grammes. 

0*1  per  cent,  aqueous  solution  of  caustic  soda  ..       50  ,, 

The  slide  is  then  passed  through  alcohol,  washed  with  water,  dried,  and 
examined. 

In  specimens  which  are  stained  by  this  method  the  protoplasm  of  the 
leucocytes  is  straw  yellow,  and  the  nuclei  are  reddish-violet ;  the  protoplasm 
of  the  epithelial  cells  is  pale  yellow,  and  their  nuclei  are  paler  than  those  of 
the  leucocytes.     The  gonococci  are  black,  and  therefore  easy  to  recognize. 

Various  stains  in  aqueous  solution  have  been  recommended  (fuchsin, 
Bumm,  Welander  ;  methyl-violet,  Bockhardt  and  Wolf  ;  Bismarck-brown, 

^  NicoUe,  "Pratique  des  Colorations  Microbiennes,"  Annates  Pasteur,  1895,  p.  964. 
2  Roman  von  Leszynski,  Ann.  de  Therap.  de  Dermatol,  et  de  Syphil. ;  Rev.  Pratique 
des  2Ial.  des  Organes  Genito-Urinaires,  Lille,  January  1,  1906,  No.  12,  p.  419. 


THE  ETIOLOGY  OF  GONOREHEA  29 

etc.).      We  are,  however,  not  convinced  that  they  present  any  marked 
advantage  over  Kiihne's  blue. 

Double  Staining. — 'Some  authors  prefer  differential  staining  of  the 
gonococci  and  the  other  elements. 

Fraenkel  stains,  to  begin  with,  the  leucocytes  and  cells  with  eosin,  a 
dye  which  does  not  affect  the  gonococcus,  and  then  he  uses  a  concentrated 
aqueous  solution  of  methylene-blue.  The  gonococci  appear  blue  on  a  red 
background  by  this  process. 

These  differential  staining  methods  are  more  complicated,  and  give 
prettier  specimens.  They  are,  however,  of  no  special  value,  as  far  as  diag- 
nosis is  concerned. 

Gram's  Method. — An  experienced  eye  can  tell  very  quickly  if  the  organisms 
seen  are  gonococci  or  not. 

Beginners,  however,  should  give  preference  to  Gram's  method,  which 
is  based  on  the  fact  that  the  gonococcus  is  decolorized  by  this  process, 
whilst  the  other  organisms  retain  their  dye. 

One  proceeds  thus : 

Once  the  preparation  has  been  dried  and  fixed,  it  is  coloured  for  a  few 
seconds  with  a  gentian  violet  solution  of  the  following  formula : 

Gentian  violet                . .              . .              . .  . .  1  gramme. 

Absolute  alcohol            .  .              . .              .  .  . .  10  c.c. 

Dissolve,  and  add  after  twenty-four  hours  : 

1  per  cent,  solution  of  carbolic  acid           . .  . .  100     ,, 

The  violet  is  then  poured  off  without  washing,  and  is  replaced  by  an 
iodine  solution: 

Iodine  . .  . .  . .  . .  . .         1  gramme. 

Potassium  iodide  . .  . .  . .  . .         2  grammes. 

Distilled  water  .  .  . .  . .  . .     200  c.c. 

This  mixture  is  allowed  to  remain  on  the  slide  for  a  few  seconds,  being 
twice  renewed  whilst  on  the  slide.  The  preparation  is  then  decolorized  in 
absolute  alcohol,  until  no  more  violet  comes  away.  The  background  is 
stained  by  means  of  a  few  drops  of  an  alcoholic  solution  of  eosin,  which  is 
left  on  for  a  minute,  and  has  the  following  composition : 

Saturated  solution  of  eosin  in  95  per  cent,  alcohol        . .     1  vol. 

95  per  cent,  alcohol  . .  . .  . .  . .     2  vols. 

Then  come  the  usual  steps  of  washing,  drying,  and  microscoping.  The 
gonococci  assume  a  pale  pink  by  this  method,  and  are  hardly  visible,  whilst 
the  ordinary  organisms  are  dark  violet. 

Instead  of  counter-staining  with  eosin,  Bismarck-brown,  according  to 

Weinrich's  formula,  may  be  used : 

Warm  distilled  water   ..  ..  ..  ..70  c.c. 

Bismarck-brown  . .  . .  . .  . .       3  grammes. 

96  per  cent,  alcohol        . .  . .  . .  . .     30  c.c. 


30 


GONORRHEA 


Staining  of  Sections. — ^For  staining  the  gonococcus  in  sections,  Wertheim 
adopts  the  following  method : 

The  section  is  left  for  three  to  five  minutes  in  a  saturated  solution  of 
gentian  violet. 

It  is  then  washed  and  dipped  into  Lugol's  solution  for  a  minute. 

One  now  decolorizes  with  95  per  cent,  alcohol.  The  preparation  must 
retain  a  definitely  violet  tint. 

After  having  transferred  it  to  a  solution  of  methylene-blue  for  a  few 
minutes,  one  washes  the  excess  of  stain  away,  dehydrates  in  absolute  alcohol, 
clears  with  oil,  and  mounts  in  Canada  balsam. 


Tig.  5. — Typical  Aspect  of  Gonococci  under  the  Microscope. 

Microscopic  Examination. — The  gonococcus  is  readily  seen  with  a  mag- 
nification of  400  diameters.  One  usually  uses  an  oil  immersion  lens  y^  with 
an  eyepiece  No.  1,  which  is  quite  sufficient. 

Distribution. — The  gonococci  are  to  be  found  either  between  or  within 
the  polymorphonuclear  leucocytes.  This  intracellular  position  is  one  of  the 
characteristic  features  of  the  gonococcus. 

Some  leucocytes  contain  only  a  few  heaps  of  gonococci,  whilst  others  are 
full  of  them,  almost  choked  with  them.  The  organisms  never  penetrate 
into  the  nucleus  of  a  cell;  they  surround  the  nuclei,  and  may  even  touch 
them,  but  they  are  never  within  their  substance. 


THE  ETIOLOGY  OF  GONOREHEA  31 

Number. — In  pus  which  is  definitely  gonorrheal  the  gonococcus  is  found 
in  large  numbers.  According  to  Finger,  the  presence  of  a  few  diplococci 
only,  even  if  they  be  intracellular,  is  not  conclusive  evidence  of  gonorrheal 
infection. 

Cultivation  of  the  Gonococcus. — The  usual  media,  such  as  agar, 
gelatin,  and  broth,  are  not  suitable  for  cultivating  the  gonococcus.  Different 
media  had  therefore  to  be  invented  which  fulfilled  the  necessary  biological 
conditions  better.  ^ 

1.  Coagulated  Human  Blood-Serum. — Bumm  was  the  first  to  obtain 
cultures  of  the  gonococcus  on  this  medium  in  1885.  He  used  a  serum  of 
placental  origin,  but  the  cultures  were  not  always  a  success. 

2.  Serum-Agar. — Wertheim  in  1893  prepared  tubes  with  2  per  cent, 
agar,  and  allowed  them  to  cool  after  sterilization.  He  then  added  to  each 
tube  one-half  or  one-third  of  its  volume  of  liquid  and  sterile  human  serum, 
and  allowed  the  tubes  to  solidify  in  a  sloping  position.  The  composition  of 
his  medium  was  as  follows : 

Agar . .             . .  . .  . .  . .  . .  2  grammes. 

Pepton             . .  . .  . .  . .  . .  1  gramme. 

Sodium  chloride  . .  . .  . .  . .  0*05        ,, 

Broth               . .  . .  . .  . .  . .  IQO  grammes. 

3.  Ascites-Agar. — As  it  is  not  always  easy  to  obtain  su£Q.cient  human 
serum,  attempts  have  been  made  to  replace  it  by  the  fluid  removed  from 
hydroceles,  pleural  effusions,  or  ascites,  and  with  success. 

Ordinary  melted  agar  is  put  into  test-tubes,  each  tube  receiving  1  c.c, 
and,  at  the  moment  when  the  agar  begins  to  set,  ^  c.c.  of  ascitic  fluid  is 
added  to  each  tube.  One  shakes  the  tubes  well,  and  allows  them  to  set  on 
the  slope. 

This  is  an  excellent  method  which  gives  well-developed  cultures  in 
twenty-four  to  forty-eight  hours  after  inoculation,  when  incubated  at  37°  C. 

4.  Ascites  Broth. — The  gonococcus  grows  well  on  a  mixture  of  equal  parts 
of  ordinary  broth  and  ascites  fluid. 

5.  Coagulated  Rabbit  Serum. — This  medium  has  been  recommended  by 
De  Christmas. 2  Unfortunately,  it  is  diflS.cult  to  prepare,  for  technical  reasons. 

6.  Pig's  Serum  :  Wassermann's  Medium.^ — Wassermann  uses  the  follow- 
ing medium,  which  is  said  to  give  colonies  after  twenty-four  hours : 

Pig's  serum,  hemoglobin -free      . .  . .  . .  15  c.c. 


Water 

Glycerine 

Nutrose 


3Q-35    „ 
2-3    „ 
80-90  centigrammes. 


^  Vide  Lefalher,  Les  Milieux  de  Culture  du  Gonocoque  (Thesis,  Paris,  1900). 

2  Annul,  d.  VInst.  Pasteur,  1897-1900. 

3  Wassermann,  Zeits.f.  Hyg.,  1898,  vol.  xxvii.,  p.  298. 


32  aONORKHEA 

This  mixture  is  shaken,  boiled  for  twenty  minutes,  and  then  mixed  with 
an  equal  part  of  2  per  cent,  pepton  containing  agar  which  has  been  liquefied 
at  50°  C.  The  mixture  is  poured  into  Petri  dishes,  and  is  ready  for  the 
cultivation  of  the  gonococcus  as  soon  as  it  has  set. 

7.  Blood- Agar. — Bezan9on  and  G-rifion  have  found  a  very  convenient 
medium  for  cultivating  the  gonococcus.  It  is  composed  of  blood-agar,  and 
is  prepared  thus  :^ 

By  means  of  a  trocar  introduced  into  the  carotid  of  a  rabbit,  blood  is 
abstracted,  and  allowed  to  flow  into  previously  prepared  tubes  which  contain 
melted  agar,  and  have  been  kept  at  50°  on  the  water-bath.  One  part  of 
blood  is  mixed  with  2  parts  of  agar  per  tube  as  intimately  as  possible,  without, 
however,  shaking  the  tubes.  The  tubes  are  then  placed  on  the  slope,  and 
allowed  to  cool.^ 

Bezan9on  and  Griffon's  blood-agar  gives  characteristic  colonies,  and  is 
an  excellent  medium  which  keeps  the  gonococci  alive  for  several  months. 

8.  Henry  HeimarCs  Medium. — Heiman^  advises  to  inoculate  the  gono- 
coccus on  a  medium  composed  of  pleural  effusion  mixed  with  2  per  cent, 
agar  to  which  1  per  cent,  pepton  and  0-5  per  cent,  salt  have  been  added. 
Sterilization  is  obtained  by  discontinued  heating  to  65°.  The  liquid  is  kept 
at  this  temperature  for  six  days.  It  is  then  left  in  the  room  for  three  days, 
and  then  again  heated  for  three  days,  as  before. 

9.  Yolk  of  Egg  Agar.'^ — This  medium  is  made  in  the  following  way:  The 
yolk  of  a  hen's  egg  is  taken,  and  one  adds  to  it  three  times  its  volume  of 
sterilized  water.  This  mixture  is  thoroughly  shaken,  and  for  every 
20  grammes  one  adds  10  grammes  of  a  20  per  cent,  solution  of  sodium 
biphosphate  and  90  grammes  of  3  per  cent.  agar.  This  final  mixture  is 
put  into  tubes  and  allowed  to  cool. 

When  inoculated  with  gonococci,  and  incubated  at  37°,  typical  rich 
colonies  develop  after  twenty-four  to  forty-eight  hours. 

Occasionally  it  is  of  great  advantage  to  be  able  to  demonstrate  the 
presence  of  gonococci  in  the  urethra  at  a  very  early  date — for  instance,  if 
one  wishes  to  attempt  abortive  treatment,  the  success  of  which  depends 
on  its  immediate  application.  Griffon^  has  given  us  a  method  by  which 
the  presence  of  the  gonococcus  can  be  ascertained  in  less  than  sixteen 
hours.     This  method  (Griffon's  method)  consists  in  the  inoculation  of  a 

1  Bezan9on  and  Grififon,  "  Culture  du  Gonocoque  sur  le  Sang  Gelose,"  Soc.  de  Biol., 
Jane  30,  1900. 

2  Bezangon  and  Griffon,  "  Le  Sang  Gelose,  ou  Milieu  de  Culture  pour  les  Microbes 
qui  ne  se  developpent  pas  sur  les  Milieux  Usuels,"  International  Medical  Congress, 
Paris,  1900. 

3  Heiman,  Medical  Record,  1896,  p.  897. 

*  Steinschneider,  Berl.  Klin.  Woch.,  1897,  p.  379. 
5  Vide  Annal.  Genito-Urin.,  1907,  p.  261. 


THE  ETIOLOGY  OF  GONORRHEA  33 

blood-agar  tube  with  a  drop  of  moisture  from  the  urethra.  By  means  of 
a  platinum  loop  which  has  been  previously  passed  through  the  flame,  one 
removes  a  little  moisture  from  the  lips  of  the  meatus,  and  inoculates  the 
blood-agar.  The  tube  is  then  capped,  and  put  into  the  incubator  for  fifteen 
to  sixteen  hours  at  37°.  Abundant  round  colonies  are  found  in  the  case 
of  a  positive  result.  The  characteristics  of  the  colonies  are :  they  are  round, 
flat,  glistening,  transparent,  and  of  a  slight  whitish  or  greyish-white  tint. 
As  the  urethra  contains  no  saprophytic  organisms  which  are  capable  of  giving 
such  rich  cultures  in  so  short  a  time  (fifteen  to  sixteen  hours),  this  method 
is  of  the  greatest  diagnostic  value.  Moreover,  it  can  be  controlled  by  micro- 
scopic examination. 

Inoculation. — The  inoculation  of  healthy  urethrse  with  pure  cultures  of 
the  gonococcus  has  been  carried  out  by  Bumm,  Aufuso,  Wertheim,  Schlagen- 
hauser,  Finger,  etc.  These  savants  succeeded  in  reproducing  experimentally 
a  typical  gonorrhea,  and  proved  thus  conclusively  the  specific  nature  of  the 
gonococcus.  It  is,  however,  not  advisable  to  imitate  these  experiments, 
because  the  results  are  too  positive.  As  evidence,  the  case  of  Ashara  may 
be  mentioned,  who  injected  the  organism  which  he  had  isolated  from  the 
blood  of  a  patient  into  a  willing  healthy  subject,  with  the  result  that  the 
latter  acquired  a  gonorrheal  septicemia  of  great  gravity. 

Bockhardt  in  1882  used  a  fourth  generation  grown  on  gelatin,  and 
inoculated  it  into  the  healthy  urethra  of  a  patient  who  was  suffering 
from  general  paralysis,  and  about  to  die.  A  urethritis  in  which  the 
gonococcus  was  found  resulted,  and  ten  days  later,  after  the  patient  had 
died  of  pneumonia,  abscesses  were  found  post  mortem  in  the  right 
kidney. 

Inoculation  of  the  conjunctiva  of  a  rabbit  with  gonorrheal  pus  has  been 
carried  out  successfully  by  Heller,  the  animal  developing  a  purulent  con- 
junctivitis. 

Finger  infected  the  joints  of  rabbits  with  gonorrheal  discharge,  and 
obtained  a  slight  inflammation  of  these  joints. 

The  intraperitoneal  inoculation  of  a  young  rabbit  is,  however,  the  only 
method  which  gives  certain  results  in  animals. 

The  inoculation  of  the  urethra  of  an  animal  with  gonorrheal  pus  has 
never  been  followed  by  a  positive  result.  Such  experiments  have  been  tried 
on  horses,  dogs,  monkeys,  and  rabbits,  without  success. 

The  Toxin  of  the  Gonocoseus. — The  researches  of  Christmas,  Wasser- 
mann,  Nicolaysen,  Schaeffer,  Scholtz,  have  shown  that  the  gonococcus 
secretes  a  poison  which,  when  injected  intraperitoneally  into  guinea-pigs 
or  white  mice,  kills  these  animals  under  characteristic  symptoms. 

According  to  Nicolaysen,^  the  gonococcal  toxin  is  an  endotoxin.      His 

^  Nicolaysen,  Centralhlatt  f.  Bakteriol.,  September,  18C7,  No.  12,  p.  305. 

3 


34  GONOEKHEA 

experiments  show  that  the  poison  is  contained  in  the  body  of  the  organism, 
and  resists  both  drying  and  heating  to  120°  C. 

Wassermann  thinks  that  the  gonotoxin  is  contained  in  the  body  of  the 
organism,  and  that  it  is  set  free  by  the  death  or  the  destruction  of  the 
coccus.  Young  cultures  contain  less  toxin  than  those  which  are  at  least 
two  weeks  old.  When  applied  to  the  urethral  mucous  membrane,  this 
toxin  produces  a  violent  purulent  inflammation  which  requires  five  days 
to  subside,  and  differs  in  its  clinical  aspect  from  true  gonorrhea  only  by  the 
absence  of  the  gonococcus. 

The  urethra  is  not  immunized  by  the  toxin,  as  the  experiment  can  be 
repeated  several  times  with  success. 

.  Biology  of  the  Gonococcus. — Neisser's  organism  is  very  susceptible  to 
changes  in  the  temperature.  It  can  grow  between  32°  and  38°  C,  the 
optimum  temperature  being  between  36°  and  38°.  Twelve  hours  at  39°, 
or  six  hours  at  40°,  are  sufficient  to  kill  it.  This  fact  explains  the  dis- 
appearance of  the  discharge  in  patients  who  suffer  from  a  fever  in  which 
the  temperature  rises  to  40°  (104°  F.).  Below  30°  the  colonies  show 
practically  no  growth,  which  ceases  completely  below  20°.  Below  18°  the 
organism  dies. 

Gonorrheal  pus  retains  its  virulence  for  some  time  at  room  temperature. 
Linen  soiled  with  gonorrheal  discharge  may  transmit  the  disease,  even  after 
a  considerable  time,  and  this  is  a  fact  of  great  importance.  In  hot  water 
the  organism  is  killed  very  rapidly. 

Relationship  between  Gonococcus  and  Meningococcus. — 'Pinto  ^  has  studied 
the  relationship  of  these  two  organisms,  which  have  certain  morphological 
and  physiological  features  in  common.  Their  staining  properties  and  their 
behaviour  when  cultivated  also  offer  points  of  similarity. 

According  to  Pinto,  the  gonococcus  is  merely  an  attenuated  meningo- 
coccus; the  two  organisms  should  be  classed  as  two  closely-allied  varieties 
of  one  species.  Their  different  pathogenic  effect  upon  man  is  largely  due 
to  adaptation,  each  having  inhabited  different  organs  for  generations  and 
generations. 

Localization  of  the  Gonococcus  in  the  Hunlan  Body. — The  urethra  of 
man  contains  no  gonococci  under  normal  circumstances. 

Although  a  parasite  of  mucous  surfaces,  this  coccus  can  enter  the  deeper 
tissues,  and  be  conveyed  by  the  blood-streams  to  distant  parts,  thus  pro- 
ducing metastases  and  a  generalized  infection.  This  condition  is  called 
gonococcal  septicemia. 

1  Pinto,  Journal  de  Phys.  et  de  Path.  Oenerale,  November  15,  1904,  p.  1058. 


THE  ETIOLOGY  OF  GONORRHEA  35 

Gonococcal  Septicemia. 

Faure-Beaulieu^  and  Lautier^  have  given  an  excellent  account  of  gono- 
coccal septicemia.  The  latter  author  describes  in  his  interesting  thesis 
three  early  and  uncomplicated  cases  of  gonorrhea  in  which  the  gonococcus 
was  present  in  the  blood,  and  was  cultivated  by  him.  Apart  from  these 
typical  and  carefully-studied  cases,  there  are  quite  a  number  of  examples  of 
gonococcemia  which  have  been  proved  such  by  the  examination  of  the  blood. 
The  micro-organism  reaches  the  general  circulation  through  the  veins, 
and  most  often  when  the  primary  lesions  involve  the  posterior  urethra  or 
the  glands  connected  with  it  (prostate,  seminal  vesicles,  testis). 

Gonococcal  septicemia  is  seldom  a  pure  septicemia.  In  most  cases  it 
produces  a  variety  of  terrible  lesions,  such  as  those  of  gonorrheal  rheuma- 
tism; in  others  it  settles  upon  certain  organs,  producing  meningitis,  pneu- 
monia, skin  lesions,  etc.  Recovery  takes  place  in  about  70  per  cent.  In 
all  fatal  cases,  with  two  exceptions,  endocarditis  was  present,  whilst  in  those 
who  recovered  a  certain  diagnosis  of  endocarditis  could  only  be  made  in 
three  instances.  Gonococcal  septicemia  thus  owes  its  gravity  chiefly  to  the 
cardiac  com'plications  which  it  is  apt  to  produce. 

In  its  manifestations,  gonococcal  septicemia  shares  the  characteristics 
of  general  m.icrobic  infections;  i.e.,  it  begins  with  fever,  which  may  be  of 
an  intermittent,  or  remittent,  or  continuous  type.^  At  the  same  time,  an 
eruption,  composed  of  pinkish  lenticular  spots,  often  appears,  which  is  not 
unlike  that  of  typhoid  fever.  The  general  health  is  affected,  but  to  so  vari- 
able an  extent  that  it  does  not  constitute  a  typical  symptom.  Marked 
pallor  and  a  sallow  tint  of  the  skin  in  general  are  constant  features.  General 
weakness  and  lassitude,  lack  of  refreshing  sleep,  and  inability  to  work  are 
the  rule.  The  relation  between  this  state  of  fatigue  and  the  gonococcus 
and  its  toxins  is  proved  by  the  astonishing  reUef  which  these  patients  obtain 
when  one  manages  to  check  the  discharge  by  means  of  irrigations  with 
permanganate. 

Although  fever  is  the  simplest  expression  of  generahzed  gonorrhea,  it 
is  barely  noticeable  in  ordinary  uncomphcated  cases.  Thus,  amongst 
twelve  cases  affected  with  acute  gonorrhea  which  came  under  Nogues' 
observation,  only  one  had  a  slight  rise  of  temperature.  Yet  it  is  true  that 
attacks  of  fever,  strongly  resembling  those  of  typhoid,^  occur  in  general 
gonococcal  septicemia,  and  that  a  hyperacute  and  hypertoxic  form  which 

1  Marcel  Faure-Beaulieu,  La  Septicemie  Gonococcique  (Thesis,  Paris,  1906). 

2  Lautier,  De  V  Utilisation  des  Procedes  de  Laboratoire  paar  la  Recherche  des  Gonocoques 
dans  le Sang  des  Blennorragiques  (Thesis,  Bordeaux,  1907). 

3  Vide  Dieulafoy,  Biill.  Acad,  de  Med.,  May  18,  1909,  p.  602. 
*  Vide  Dieulafoy,  loc.  cit. 


36  GONOERHEA 

takes  a  very  rapid  course  exists.  This  galloping  form  might  very  well  be 
termed  malignant  gonorrhea. 

Dieulafoy  quotes  an  instance  which  was  brought  to  his  notice  by  Cherrer, 
a  military  surgeon:  A  young  soldier,  sufiering  from  gonorrhea  for  a  fort- 
night, was  admitted  to  the  Military  Hospital  because  he  felt  seedy.  His 
temperature  soon  rose  to  38°,  39°,  and  even  40°  C.  A  provisional  diagnosis 
of  typhoid  fever  was  made,  and  the  Widal  test  was  done ;  but  the  result  was 
negative.  A  few  days  later  a  pleural  effusion  was  diagnosed,  and  on  aspira- 
tion a  turbid  fluid,  full  of  gonococci,  was  withdrawn.  The  patient  collapsed; 
and  died  soon  afterwards.  At  the  autopsy  the  disease  was  found  to  be 
generalized  gonorrhea.  There  was  no  trace  of  any  typhoid  lesions.  The 
patient  had  died  of  gonococcal  septicemia;  his  peritoneum  was  inflamed, 
and  covered  with  an  exudate  which  contained  gonococci. 

Thayer  has  published  a  similar  case :  A  young  man  who  had  had  gonorrhea 
for  three  months,  was  suddenly  taken  ill  with  general  malaise,  and  fever 
rising  to  104°  F.  The  Widal  test  was  negative,  and  thus  the  original  diag- 
nosis of  typhoid  fever  was  discarded.  The  blood  was  then  examined,  and 
gonococci  were  cultivated  from  it. 

These  examples  prove  clearly  that  the  gonococcus  can  reach  the  general 
circulation,  and  they  show  the  value  of  a  bacteriological  examination  of  the 
blood  for  clinching  the  diagnosis. 

For  this  purpose,  a  considerable  quantity  of  blood  (10  to  20  c.c.)  should 
be  taken  during  a  febrile  attack.  The  best  culture  media  are,  according  to 
Faure-Beaulieu,  the  liquid  media  of  the  ascites-broth  type.  Faure-Beaulieu 
incubates  these  media,  once  they  have  been  inoculated,  for  twenty-four 
hours,  and  then  makes  subcultures  on  ascites-agar.  In  forty-eight  hours 
this  method  yields  typical  colonies  of  the  gonococcus. 

The  isolation  and  cultivation  of  the  organism  is,  however,  not  easy,  and 
even  under  the  best  conditions  one  meets  occasionally  with  failures.  Thus, 
Harris  and  Johnson  failed  to  find  the  gonococcus  on  two  out  of  five  occasions 
on  which  they  examined  the  blood  of  the  same  patient.  Faure-Beaulieu  was 
also  unsuccessful  in  three  out  of  four  attempts  under  similar  circumstances. 

It  seems  as  if  the  fever  did  not  progress  in  a  steady,  continuous  manner, 
but  that  discharges  of  microbes  into  the  circulation  took  place  at  odd  times ; 
clinically,  the  intermittent  or  remittent  attacks  of  fever  would  correspond 
to  them. 

Courtois-SuflS.t  and  Beaufume^  have  reported  a  fatal  case  of  generalized 
gonorrhea  in  which  this  condition  followed  upon  a  benign  intervention  on 
the  urethra,  and  on  the  repeated  passing  of  catheters.  A  severe  infection 
supervened  which  was  characterized  by  multiple  abscesses,  and  ended 
fatally.     In  all  the  abscesses  and  in  the  blood  typical  gonococci  were  found 

^  Courtois-Saffit  and  Beaufume,  Soc.  lied,  des  Hopitaux  de  Paris,  April  14,  1905. 


THE  ETIOLOGY  OF  GONOEKHEA  37 

— namely,  in  the  pus  taken  from  the  right  brachial  and  sural  triceps  muscles, 
the  posterior  surface  of  the  sternum,  the  left  thigh,  and  the  left  testicle  and 
epididymis. 

As  long  as  there  are  gonococci  in  the  urethra,  general  infection  is  liable 
to  occur.  Even  when  the  disease  is  confined  to  the  anterior  portion,  or  if 
it  has  assumed  a  torpid  form,  the  local  trouble  may  spread,  and  cause  general 
havoc.  This  may  occur  spontaneously  or  without  any  cause  which  we  are 
able  to  account  for. 

Thevenot  and  Michel  have  pubHshed  quite  recently  a  case  of  hemorrhagic 
septicemia  which  came  on  during  an  attack  of  gonorrhea,  and  killed  the 
patient.  A  man  of  thirty-one,  who  had  been  sufiering  for  sixteen  months 
from  a  neglected  attack  of  gonorrhea,  was  suddenly  taken  seriously  ill. 
Apart  from  his  bad  general  condition,  he  showed  an  eruption  of  purpura  on 
his  neck  and  his  abdomen,  and  developed  hemorrhages  from  his  nose  and 
mouth,  dying  shortly  afterwards.^ 

Weitz  of  Hamburg  had  about  the  same  time  a  fatal  case  of  gonococcal 
septicemia,  in  which  severe  icterus,  cutaneous  hemorrhages,  stupor,  fever, 
and  albuminuria,  were  observed.  Cultivation  of  the  patient's  blood — a 
youth  of  nineteen — yielded  typical  gonococci.^ 

Ulmann  has  also  met  with  a  case  of  gonorrheal  endocarditis  which  de- 
de loped  severe  jaundice  when  the  end  was  near. 

We  owe  to  Colombini^  the  history  of  a  remarkable  case  of  gonococcal 
septicemia :  A  man  of  twenty-eight  acquired  gonorrhea,  and  was  insufficiently 
treated.  After  a  fortnight  a  bubo  appeared  in  the  left  groin,  which  had  to 
be  incised,  and  with  it  a  left  epididjnuitis,  which  finally  suppurated.  The 
fever  rose  to  39*8°  C,  and  lasted  for  two  weeks  or  so.  In  the  meantime 
the  patient  wasted  away,  and  developed  a  metastatic  abscess  in  his  right 
parotid  which  required  incision.  The  gonococcus  was  present  in  the  pus 
from  the  urethra,  and  from  the  abscesses  in  groin,  scrotum,  and  parotid. 
The  blood  which  was  taken  from  one  of  the  brachial  veins  was  found  sterile 
on  the  first  occasion.  The  second  attempt  yielded  a  culture,  and  with  the 
culture  of  the  third  bleeding  the  urethra  of  another  youth  was  successfully 
inoculated. 

In  order  to  trace  cases  of  gonococcal  septicemia,  one  has  recently  resorted 
to  the  complement-fixation  reaction,  and  thus  established  for  gonorrhea  a 
reaction  similar  to  Wassermann's  reaction  for  syphilis. 

GradwohH  has  made  use  of  this  serum  reaction  in  fifty  cases,  following 
the  technique  indicated  by  Neil  and  Schwartz,  and  Wassermann's  method. 

1  Thevenot  and  Michel,  Province  Medicale,  May  18,  1912,  No.  20,  p.  228. 

2  Weitz,  Medizin.  Klinik,  February  4,  1912. 

3  Colombini,  Centralblatt  f.  Balcteriol.,  vol.  xxix..  No.  25,  p.  955. 

*  Gradwohl,  American  Journal  of  Dermatology  and  Genito-Urinary  Diseases,  June, 
1 912,  vol.  xvi..  No.  6,  pp.  294-299. 


38  GONOKRHEA 

His  conclusions  are  favourable,  and  seem  to  indicate  that  this  test  would 
be  useful  for  the  detection  of  latent  gonococcal  septicemia.  The  reaction 
only  becomes  positive  when  a  posterior  urethritis  of  three  weeks'  duration 
is  present,  and  does  not  disappear  when  only  an  anterior  urethritis  is  left. 
For  the  diagnosis  of  gonorrhea  in  the  female  this  reaction  would  be  of  great 
value,  as  the  gonococcus  is  often  very  diflS.cult  to  find  in  women;  moreover, 
it  might  help  in  the  di:fferential  diagnosis  of  pelvic  inj&ammations.  The 
change  of  a  positive  reaction  into  a  negative  one  would  indicate  that  the 
patient  has  got  rid  of  his  disease;  the  clinical  cure,  however,  precedes  the 
serological  cure,  as  it  takes  the  system  about  thirty  days  to  eliminate  the 
specific  bodies. 


CHAPTER  IV 

INFLAMMATIONS  OF  THE   URETHRA  DUE   TO   OTHER  CAUSES 
THAN  THE  GONOCOCCUS 

There  are  a  considerable  number  of  urethral  inflammations  wbicb  are  not 
caused  by  the  gonococcus,  and  differ  in  their  symptoms  from  ordinary 
gonorrhea — namely : 

1.  Inflammations  of  the  urethra  due  to  common  micro-organisms. 

2.  Inflammations  of  the  urethra  said  to  be  "  aseptic." 

3.  Inflammations  of  the  urethra  due  to  chemicals. 

4.  Inflammations  of  the  urethra  due  to  a  special  diathesis. 

5.  Inflammations  of  the  urethra  of  toxic  origin. 

6.  Inflammations  of  the  urethra  of  traumatic  origin. 

1.  Inflammations  of  the  Urethra  due  to  Common  Miero-Organisms. 

One  often  meets  with  inflammations  of  the  urethra  which  are  not  caused 
by  the  gonococcus,  and  it  is  a  great  mistake  to  think  that  they  are  not  in- 
fectious owing  to  the  absence  of  Neisser's  organism.  On  the  contrary,  these 
non-gonococcal  urethrites  are  infectious,  and  apt  to  cause  serious  complications 
in  the  male,  although  they  assume  as  a  rule  a  torpid  form  in  the  female 
(slight  metritis).  The  infectious  character  of  these  inflammations  is  rendered 
evident  by  the  frequency  with  which  they  lead  to  epididymitis,  prostatitis, 
and  vesiculitis.  Despite  their  apparent  benignity,  they  thus  deserve  to  be 
followed  up,  and  to  be  treated  until  they  are  cured.  The  complications 
they  expose  to  are  sufficient  argument  for  this  line  of  conduct. 

These  common  non-specific  urethrites  of  bacterial  origin  occur  under  two 
absolutely  different  conditions,  which  may  be  termed  primary  and  secondary. 

1.  Primary  Urethritis  of  Bacterial  Origin  is  observed  after  intercourse 
with  a  woman  who  suffers  from  a  profuse  discharge,  and  who  takes  little 
care  of  her  person. 

Janet  ^  has  described  two  instances  in  which  the  wives  developed  inflam- 
matory lesions  after  having  married  husbands  who  suffered  from  a  non- 

1  Janet,  Annal.  des  Malad.  des  Organes  Genito-Urin..  1893.  pp.  600  and  601. 

39 


40  GONOEEHEA 

specific  urethritis.  In  their  utero-vaginal  secretions  abundant  small  short 
bacilli  were  found  which  were  identical  with  those  present  in  the  urethras 
of  their  husbands. 

I  have  observed  several  absolutely  similar  cases.  One  of  them  relates 
to  a  patient  whose  exemplary  conduct  was  beyond  suspicion.  He  wa^ 
forty-one  years  of  age,  had  been  married  for  fourteen  years,  and  was  the 
father  of  three  children.  After  the  birth  of  her  three  children,  the  wife 
had  had  three  miscarriages,  and  subsequently  suffered  from  leucorrhea. 
She  paid  no  attention  to  her  trouble,  and  did  not  even  use  a  vaginal  douche. 
The  man  had  never  had  gonorrhea,  and  had  also  always  been  true  to  his 
wife  since  his  marriage.  Two  months  before  he  consulted  me  he  developed 
a  profuse  discharge.  When  he  came  to  me  I  examined  his  discharge,  and 
found  a  great  number  of  common  microbes,  but  no  gonococci.  I  resorted 
to  irrigations  with  oxycyanide  of  mercury,  and  obtained  a  rapid  improve- 
ment. A  complete  cure  was,  however,  only  effected  after  a  lengthy  and 
methodical  dilatation  treatment. 

Another  interesting  observation  was  made  on  a  medical  man.  Our 
colleague  had  a  urethritis  of  streptococcal  origin,  which,  as  he  assured 
me,  followed  upon  an  intercourse  with  a  woman  who  had  suffered  from 
erysipelas. 

Inflammations  of  the  uterus  and  the  appendages  may  under  certain 
circumstances  cause  a  urethritis,  as  well-authenticated  examples  show. 

Legrain-^  knew  of  a  medical  student  who,  after  having  restrained  his 
desires  for  a  fortnight,  had  connection  with  a  woman  who  had  been  treated 
two  months  previously  for  a  retro-uterine  abscess.  This  intercourse  was 
followed  after  twenty-four  hours  by  an  abundant  greenish  discharge,  in 
which  bacteriological  examination  revealed  the  presence  of  the  Micrococcus 
cceruleus  alhus. 

2.  Secondary  Urethritis  of  Bacterial  Origin. — They  are  very  frequent, 
and  are  found  in  patients  who  have  had  repeated  attacks  of  gonorrhea,  and 
from  whose  urethra  the  gonococcus  has  disappeared  for  some  time.  They 
are  often  most  difl&cult  to  cure,  and  require  special  attention.  Sometimes 
they  are  kept  up  by  a  prepuce  of  excessive  length.  In  cases  of  this  kind  a 
chronic  balanoposthitis  is  set  up,  from  which  the  organisms  find  their  way 
into  the  urethra. 

I  have  had  occasion  to  examine  a  young  man  who  had  been  irrigating 
himself  for  over  a  year  with  oxycyanide  of  mercury.  He  searched  every 
morning  for  his  bead  of  pus,  and  sent  it  to  a  laboratory  for  analysis.  In- 
variably the  following  reply  came  back:  "  Ordinary  organisms  only :  staphy- 
lococci, streptococci  .  .  ."  This  induced  him  to  increase  the  number  of 
his  irrigations,  and  this  performance  went  on  for  a  year  or  more.    When  I 

1  Legrain,  Annul,  des  Malad.  des  Organes  Oenito-  Urin.,  August,  1888,  and  June,  1889. 


INFLAMMATIONS  OF  UEETHRA  NOT  DUE  TO  GONOCOCCUS    41 

examined  him,  I  found  in  the  first  glass  a  few  very  light  and  slender  fila- 
ments, which  contained  no  bacteria.  His  infection  was  confined  to  his 
meatus,  and  was  due  to  common  organisms.  Washing  the  meatus  with  a 
1  :  4000  solution  of  perchloride  of  mercury,  and  dusting  it,  as  well  as  the 
balano-preputial  sulcus,  with  an  inert  powder,  cured  him  readily. 

Then,  again,  we  find  cases  of  urethritis  persisting  simply  because  the 
urethral  epithelium  has  been  so  damaged  by  the  gonococcus  that  it  is  com- 
pletely modified,  and  has  become  unable  to  resist  the  action  of  the  conmion 
micro-organisms .  It  is  well  known  that  the  normal  epithelium  of  the  urethra, 
which  is  cylindrical,  has  a  great  bactericidal  power  on  ordinary  bacteria. 
Once  the  mucous  membrane  loses  its  cylindrical  cells,  and  has  them  replaced 
by  a  pavement  epitheHum,  its  microbicidal  power  vanishes. 

This  type  of  non-gonococcal  urethritis  is  the  most  common. 

All  those  whose  lot  it  is  to  treat  gonorrhea  should  bear  this  point  in  mind. 
They  often  have  to  advise  young  men  who  wish  to  marry,  and  desire  to 
get  rid  of  their  gonorrhea  previously.  Once  a  careful  and  conscientious 
treatment  has  removed  all  infection,  once  repeated  and  thorough  examina- 
tions allow  one  to  permit  the  marriage,  it  is  well  to  warn  them  that  they 
may  develop  a  discharge  after  their  marriage.  This  discharge  is  not  due 
to  gonococci  which  have  remained  latent,  but  to  common  micro-organisms. 
The  young  wife  is  very  generally  in  a  state  of  complete  ignorance  of  sexual 
hygiene,  and  has  no  experience  of  vaginal  injections.  Moreover,  the  lacera- 
tions caused  by  defloration  often  form  wounds,  which  suppurate  sHghtly. 
Under  these  conditions  there  is  sufficient  microbic  activity  to  infect  the 
husband's  weakened  urethra. 

I  have  had  many  opportunities  of  verifying  these  statements.  One 
case,  which  is  of  special  interest,  may  be  quoted : 

A  young  officer  had  had  a  chronic  urethritis  oi  very  long  standing,  which  I  had 
cured  completely  by  means  of  appropriate  treatment.  Not  only  the  discharge,  but 
also  all  filaments,  had  completely  disappeared.  Under  observation  without  treatment 
ior  a  month  before  his  marriage,  he  never  showed  the  slightest  trace  of  illness,  and  his 
urine  was  always  quite  clear  and  free  from  filaments.  Aiter  a  final  complete  urethro- 
scopic  examination  I  gave  my  consent  to  his  marriage.  Only  eight  days  after  the 
wedding,  whilst  he  was  away  on  his  honeymoon,  anxious  telegrams  arrived  which 
informed  me  that  his  discharge  had  reappeared,  and  was  as  bad  as  ever.  Smear  prepara- 
tions made  by  the  patient  came  soon  aiter,  and  allowed  me  to  diagnose  his  discharge  as 
being  due  to  adventitious  organisms.  I  was  thus  able  to  reassure  him,  and  I  advised  him 
to  give  himself  a  few  irrigations  with  mercury  oxycyanide,  which  had  the  desired  effect. 

Quite  a  number  of  books  have  been  published  on  the  flora  of  the  urethra. 
There  is  thus  no  need  for  a  lengthy  enumeration^  of  all  the  organisms  which 
have  been  found  in  urethral  discharges.  The  most  important  ones  are — 
Streptococcus,  Bacillus  cob,  pneumococcus,  staphylococcus,  various  sarcinse, 

1  Rousseau,  Contribution  a  la  Flore  des  Uretrites,  (Paris,  Pharmaceutical  Thesis,  1905). 


42 


GONOEKHEA 


diphtheria  bacillus,  tubercle  bacillus,  Micrococcus  fallax,^  and  M.  cseruleus 
albus  (Legrain).  One  of  the  microbes  most  often  found  is  a  small,  short, 
slender  bacillus,  arranged  in  chains  or  clusters,  and  present  in  great  quantity. 
This  organism,  which,  according  to  Finger,  is  a  usual  saprophyte  of  the 
prepuce,  is  met  with  in  cases  of  long  standing  which  have  lasted  for  ages, 
and  have  been  treated  for  a  considerable  period.  It  is  practically  never 
found  in  a  healthy  urethra  which  has  never  been  infected.  The  accom- 
panying discharge  contains  but  very  few  leucocytes,  or  none.  One  finds, 
however,  the  large  flat  cells  of  the  urethral  epithelium,  either  isolated  or  in 
apposition,  and  around  and  within  them  the  bacilli  (Figs.  6  and  7).^ 


Fig.  6. — Secondaby  Infection  :  Numerous  Small  Bacilli  and  Epithelial 

Cells.     (Wossidlo.) 


To  this  group  may  be  added  those  urethrites  which  follow  upon  systemic 
infections.  Legrain  noted  a  case  in  which  the  urethritis  came  on  after 
typhoid  fever.  The  bacteriological  examination  revealed  the  presence  of 
M.  pyogenes  aureus.^  Gravis  and  Stievenard,'^  Billoir,^  and  Schmitt,^ 
observed  urethrites  following  upon  mumps.  Moscato"^  had  a  patient  of 
sixty  who  developed  a  discharge  from  his  urethra  every  time  he  had  an 
attack  of  intermittent  fever,  and  which  invariably  disappeared  after  the 
attack.  Dr.  Morisz  Porosz,  of  Budapest,  has  published  an  interesting  paper 
on  this  subject.^ 

1  Vide  Geraud,  "Saprophytic  Uretrale  Pseudo-Membraneuse,"  G.  B.  de  FAss. 
FmnQaised'Urologie,  1907,  p.  271.        ^  Legrain,  Thesis,  Nancy,  1888. 

3  Annul.  Genito-Urin.,  1889.  ^  Bullet,  de  Therap.,  vol.  xxix.,  p.  145. 

5  Gazette  Hebdom.,  1859,  p.  117.      ^  Arch,  de  Med.  et  de  Pharm.  MUit.,  1883. 

7  /Of orgrag'nt,  November,  1890.      ^  Fovosz,  Monatsberichtef.  Urologie,Yo\.ix.,  1904. 


INFLAMMATIONS  OF  UEETHRA  NOT  DUE  TO  GONOCOCCUS    43 


2.  So-called  "Aseptic"  Inflammations  of  the  Urethra. 

The  so-called  "  aseptic  "  inflammations  of  the  urethra  are  characterized 
by  the  fact  that  their  discharge  never  contains  any  gonococci  or  other  micro- 
organisms. All  one  sees  under  the  microscope  is  a  great  number  of  leuco- 
cytes and  a  few  epithelial  cells.  Even  if  one  tests  the  mucosa  by  the  reaction 
test,  .either  by  an  injection  of  silver  nitrate  or  by  giving  the  patient  plenty 
of  beer  or  champagne,  one  finds  no  change  in  the  character  of  the  discharge. 
No  fresh  organisms  appear  which  could  be  shown  by  the  ordinary  staining 
methods. 


Fig.  7. — Secondaky  Infection:  Organisms  arranged  in  Chains. 

(Wossidlo.)i 

These  inflammations  deserve  thus  rightly  the  name  "  aseptic  "  given 
to  them.  They  correspond  fairly  well  to  what  is  known  to  the  layman  as 
"  echaufiement." 

They  have  been  known  for  a  long  time,  and  have  been  studied  by  Nogues, 
Guiard,  and  others.     Their  pathology  is,  however,  not  clear. 

The  following  features  are  peculiar  to  them :  They  are  always  caused  by 
excessive  drink  and  exercise,  and,  above  all,  excessive  indulgence  in  sexual 
intercourse.  Connections  which  last  long  or  take  place  at  the  time  of  the 
periods  are  especially  dangerous. 

Their  incubation,  if  this  term  may  be  used,  is  much  longer  than  that  of 
genuine  gonorrhea;  it  is  usually  more  than  eight  days.     Sometimes  three 

^  Figs.  6  and  7  are  taken  from  Wossidlo,  Die  Gonorrhoe  des  Mannes,  unci  Hire 
Komplicationen,  Berlin,  1903. 


44  GONOREHEA 

weeks  elapse  after  the  last  intercourse  before  they  appear.  Tlie  onset  is 
usually  torpid,  and  produces  no  painful  reaction  on  the  part  of  the  urethral 
mucous  membrane. 

The  aspect  of  the  discharge  is  the  same  as  that  of  gonorrhea.  It  is, 
however,  usually  less  free.  It  is  yellowish- white  or  milky,  but  it  never 
becomes  greenish  or  green.  Under  the  microscope  only  leucocytes,  but  no 
organisms,  are  seen. 

There  is  no  pain  worth  speaking  of  on  making  water,  or  during  an  erec- 
tion. The  urine  is  nearly  always  clear  in  both  glasses,  but  it  contains  a 
greater  or  lesser  quantity  of  filaments. 

The  patient  recognizes  his  trouble  usually  by  the  spots  on  his  linen  or 
by  a  tickling  sensation  in  his  urethra.  Further  inspection  then  shows  him 
the  scanty  milky  discharge. 

I  have  been  able  to  examine,  in  a  great  number  of  instances,  the  women 
who  were  accused  of  being  the  contaminating  persons .  Repeated  examinations 
never  enabled  me  to  discover  any  gonococci  in  the  urethra,  or  in  the  cervix, 
or  elsewhere.  I  was,  however,  always  able  to  find  some  lesion  of  the  genito- 
urinary organs.  Some  had  a  metritis,  others  a  salpingitis,  etc.  A  completely 
healthy  woman  has  never  come  under  my  observation  in  these  instances. 

A  further  characteristic  feature  of  these  urethrites  is  that  they  are 
readily  cured  with  silver  nitrate,  and  that  they  are  prone  to  recur. 

I  have  been  able  to  examine  and  to  follow  up  a  urethritis  of  this  type  in  a  house- 
surgeon,  twenty-six  years  of  age.  He  consulted  me  on  May  30,  1901,  for  a  urethritis 
which  he  had  had  for  three  weeks.  His  urine  was  clear,  but  there  were  filaments  in  the 
first  glass.  Micturition  and  erection  did  not  give  rise  to  any  pain.  A  careful  micro- 
scopic examination  of  his  discharge  showed  nothing  but  leucocytes.  He  was  put  under 
the  reaction  test ;  an  injection  with  1  :  1,000  silver  nitrate  solution  was  given,  and  he 
drank  beer  freely.     Next  day  his  discharge  was  less. 

The  irrigations  with  silver  nitrate  were  repeated  on  the  next  three  days,  with  the 
result  that  the  discharge  and  the  filaments  disappeared  completely.  At  the  end  of 
June,  1901,  he  had  no  trace  of  any  discharge,  and  remained  well  for  six  months.  Then, 
on  January  9,  1902,  he  returned  with  a  similar  discharge.  He  assured  me  that  he  was 
still  with  the  same  woman,  and  that  he  had  been  true  to  her.  The  intercourse  which 
had  apparently  brought  the  discharge  on  again  was  prolonged,  and  took  place  just  before 
her  periods  came  on.  Examination  of  the  pus  was  again  negative,  only  pus  cells  being 
found,  and  the  same  treatment  produced  again  a  rapid  recovery. 

Some  of  these  aseptic  urethral  inflammations  last  very  long.  Just  as 
they  are  slow  in  appearing,  they  are  reluctant  to  disappear,  and  if  left  to 
themselves  they  may  last  for  ever. 

Usually  the  anterior  urethra  is  alone  affected,  and  the  pathogenic  factor 
seems  to  be  located  chiefly  in  Littre's  glands  of  the  penile  portion.  This  is 
readily  seen  to  be  so  if  one  collects  the  patient's  urine  in  four  glasses.  The 
first  one  only  contains  a  great  number  of  small,  light,  comma-shaped  fila- 
ments— a  characteristic  feature  of  pronounced  littritis. 


INFLAMMATIONS  OF  URETHRA  NOT  DUE  TO  GONOCOCCUS     45 

The  best  treatment  for  these  inflammations  of  the  urethra  is  silver 
nitrate,  appHed  in  a  0-1  per  cent,  sohition  as  irrigations,  which  should  be 
given  daily  with  an  irrigator. 

Once  the  first  glass  of  urine  has  become  perfectly  clear,  methodical 
dilatations  are  resorted  to — first  with  curved  sounds,  and  then  with  Koll- 
mann's  four-bladed  dilator.  This  dilatation  treatment  is  best  combined 
with  silver  nitrate  irrigations,  and  should  be  continued  until  the  meatus  is 
perfectly  dry,  and  until  there  are  no  more  filaments  in  the  urine. 

Amongst  this  group  of  "  aseptic  urethrites  "  may  also  be  placed  those 
secondary  inflammations  of  the  urethra  which  follow  upon  primary  infec- 
tions of  the  bladder  or  of  the  kidney,  or  are  secondary  to  such  anatomical 
lesions  as  strictures,  papillomata,  polypi,  and  ulcerations  of  the  urethra; 
chronic  prostatic  lesions,  and  those  of  the  lacunae  of  Morgagni  and  of  Littre's 
glands. 

They  deserve  great  attention,  because  they  are  often  the  first  symptom 
of  an  infection  of  the  urinary  organs  of  the  utmost  gravity.  They  are  not 
infrequently  the  sign  of  a  tuberculous  urethritis  which  itself  is  a  secondary 
manifestation  of  an  already  existing  infection  of  the  genito-urinary  tract 
by  Koch's  bacillus.  Tuffier  and  Girod  have  published  a  case  of  this  kind, 
Lavaux  communicated  another  one  at  the  Surgical  Congress  in  1898,  and 
Jamin  quotes  several  interesting  examples  in  his  thesis.  The  pathological 
changes  which  give  rise  to  the  discharge  are  nearly  always  situated  at  the 
level  of  the  prostate  or  of  the  seminal  vesicles.  Careful  palpation  of  the 
epididymis,  of  the  prostate,  and  of  the  seminal  vesicles  allows  one  to  find 
nodules  in  one  ox  more  of  these  organs,  and  thus  to  clinch  the  diagnosis. 


3.  Inflammations  of  the  Urethra  due  to  Chemicals. 

Chemical  urethrites  are  usually  caused  by  the  injection  of  irritating  sub- 
stances which  produce  a  desquamation  of  the  urethral  epithelium,  and 
thus  open  a  channel  of  entry  for  saprophytic  organisms. 

Many  patients  are  haunted  by  the  long  duration  of  their  discharge,  and 
try  to  remedy  the  evil  by  irritating  antiseptic  injections,  which  they  con- 
tinue daily  for  weeks  or  months.  They  thus  themselves  produce  a  dis- 
charge, which  they  try  to  get  rid  of  by  more  injections,  and  naturally  with- 
out success,  the  only  way  of  stopping  their  discharge  being  to  give  up  all 
therapy. 

One  of  the  drugs  which  is  most  apt  to  keep  up  a  discharge  is  oxycyanide 
of  mercury.  It  is  well  to  inform  the  patients  of  this  fact,  and  to  advise 
them,  if  they  are  using  this  substance,  not  to  inject  more  often  than  once 
every  three  or  four  days ;  otherwise  their  discharge  may  persist  indefinitely. 


46  GONORRHEA 

4.  Inflammations  of  the  Urethra  due  to  a  Special  Diathesis. 

This  group  of  urethrites  is  exceedingly  rare.  Very  few  of  the  cases  of 
urethritis  recorded  in  the  past  as  being  due  to  a  special  diathesis  can  with- 
stand the  criticism  which  our  advanced  knowledge  of  the  disease,  and  our 
modern  accurate  means  of  diagnosis  enable  us  to  make.  A  "  diathesis  " 
can  only  be  regarded  as  a  predisposing  factor ;  the  chief  cause  in  these  cases 
is  always  a  microbic  infection. 

The  occurrence  of  a  urethritis  due  to  a  special  diathesis  has  been 
described — 

1.  In  the  case  of  rheumatic  fever.  Martineau  reported  in  Turbur's 
thesis  (1887)  the  case  of  a  child  of  fourteen  who  suffered  from  subacute  poly- 
articular rheumatism  for  three  weeks.  As  long  as  the  disease  lasted,  this 
boy  had  a  discharge  from  his  urethra,  which  disappeared  with  the  attack. 
Later  in  life,  he  had  three  further  attacks  of  rheumatism,  and  on  each  occa- 
sion he  developed  a  profuse  purulent  urethral  discharge.  The  urethritis 
formed  thus  part  and  parcel  of  his  rheumatism,  and  its  onset  could  be 
predicted  as  soon  as  the  first  pains  were  felt  in  the  joints. 

2.  Arthritism,  herpetism,  and  gout,  are  also  held  responsible  for  urethral 
inflammation  by  certain  authors.  But  these  cases  are  very  doubtful.  At 
the  most,  one  may  concede  that  these  diatheses  are  predisposing. 

3.  According  to  Hamonic,^  inflammation  of  the  urethra  occurs  in  diabetes 
without  infection.  He  observed  a  case  of  this  nature  in  a  young  subject 
affected  with  glycosuria,  and  he  noticed,  to  his  great  astonishment,  that 
the  urethritis  ceased  almost  immediately  after  a  suitable  diet  and  treatment 
had  stopped  the  glycosuria.  In  the  following  years  the  urethritis  recurred 
each  time  the  glycosuria  came  on  again.  Hamonic  suggests  two  alterna- 
tive explanations.  In  some  cases  the  diabetics  have  a  long  prepuce,  under 
which  germs  develop.  The  stagnation  of  a  few  drops  of  urine  favours  their 
growth,  and  thus  leads  to  an  infection  of  the  urethra.  Or  one  must  consider 
that  the  urine  loaded  with  sugar  has  a  direct  irritant  effect  upon  the  urethral 
mucous  membrane.  At  any  rate,  a  urethritis  of  this  kind  depends  upon 
exacerbations  of  the  glycosuria,  which  therefore  should  be  treated;  and  the 
improvement  of  the  urethral  trouble  will  depend  upon  the  influence  of 
appropriate  diet  and  hygiene,  and  of  arsenic  and  lithium  alkali,  upon  the 
glycosuria. 

5.  Inflammations  of  the  Urethra  due  to  Toxms. 

Certain  inflammations  of  the  urethra  have  been  noted  after  the  intake 
of  certain  kinds  of  food,  such  as  asparagus  and  strawberries. 

Schenck  mentions  the  case  of  a  man  who  could  produce  a  discharge 

1  Hamonic,  "De  I'Uretrite  chez  les  Diabetiques,"  Ass.  Fran9aise  d'Urologie,  1908, 
p.  129. 


INFLAMMATIONS  OF  URETHRA  NOT  DUE  TO  GONOCOCCUS    47 

from  his  urethra  at  will  by  eating  cress.  Harrison  observed  a  patient  who 
had  a  copious  urethral  discharge,  which  lasted  five  days,  after  having 
indulged  freely  in  asparagus. 

The  use  of  certain  drugs  is  also  apt  to  give  rise  to  a  discharge  from  the 
urethra.  Cantharides  inflames  the  whole  urinary  system,  and  thus  it  may 
lead  to  cystitis  and  urethritis.  Nitrate  of  potash  produced  an  intense 
urethritis  in  one  of  Lallemand's  patients,  who  had  taken  30  grammes  (about 
450  grains)  of  this  drug.  Mercier  saw  a  similar  case  in  which  potassium 
iodide  had  been  taken.  The  arsenical  preparations  have  also  been  in- 
criminated (Savignac,  Delacour,  Saint-Philippe). 


6.  Inflammations  of  the  Urethra  of  Traumatic  Origin. 

A  traumatic  urethritis  is  caused  by  the  passage  or  sojourn  of  foreign 
bodies  in  the  urethra.  It  is  common  knowledge  that  the  use  of  a  permanent 
catheter  is  always  followed  by  suppuration  of  the  canal. 

In  this  group  one  may  also  include  those  inflammations  which  follow 
upon  venereal  excesses.  Cases  of  this  kind  have  been  reported  to  occur 
from  masturbation,  and  Ricord  published  the  case  of  a  doctor  who,  after 
a  period  of  six  weeks'  chastity,  had  passed  a  whole  day,  from  10  a.m.  till 
7  p.m.,  in  a  state  of  frenzy  in  the  company  of  a  woman  whom  he  loved, 
and  who  refused  to  yield.  Three  days  later  he  had  a  violent  and  painful 
inflammation  of  his  urethra. 


CHAPTER   V 

THE  ANATOMY  OF  THE  URETHRA,  AND  THE  PATHOLOGY  OF 

GONORRHEA 

It  is  only  of  late  that  the  study  of  gonorrhea  has  made  great  strides.  For 
a  very  long  time  all  knowledge  of  this  disease  was  based  on  the  crudest 
empiricism,  and  the  treatment  was  purely  a  matter  of  routine.  Anatomical 
and  pathological  studies  were  practically  non-existent. 

Since  more  attention  has  been  paid  to  anatomical  conditions  and  to 
pathological  findings,  such  great  progress  has  been  made  that  it  has  become 
possible  to  build  up  a  rational  and  efficient  therapy.  A  sound  know- 
ledge of  the  anatomical  and  pathological  facts  is  indispensable  for  the 
making  of  a  correct  diagnosis  and  for  carrying  out  a  sound  treatment; 
hence  the  importance  of  this  chapter. 

THE  ANATOMY  OF  THE  URETHRA. 

It  is  not  our  intention  to  give  here  a  complete  anatomical  description  of 
the  urethra.  Only  those  points  will  be  mentioned  which  we  consider  essen- 
tial for  the  understanding  of  the  persistence  of  "  rebellious  gleet,"  and  of 
certain  methods  of  treatment. 

I.  The  Male  Urethra. 

The  urethra  is  the  channel  through  which,  in  both  sexes,  the  urine  passes 
from  the  bladder,  where  it  has  been  stored,  to  the  outside.  In  the  male 
the  urethra  extends  from  the  neck  of  the  bladder  to  the  tip  of  the  glans 
penis;  into  it  open  the  ejaculatory  ducts,  and  thus  it  also  acts  as  channel 
for  the  sperma. 

Course. — The  urethra  describes,  on  its  way  from  the  neck  of  the  bladder 
to  the  root  of  the  penis,  a  curve  with  a  concavity  directed  upwards  and 
forwards.  In  front  of  the  symphysis  pubis  it  bends  down,  and  runs  along 
the  under-surface  of  the  penis.  The  urethra  thus  describes  two  curves, 
which  form  together  an  italic  S.  Of  these  two  curves,  only  the  posterior 
one  is  permanent;  the  other  one  disappears  when  the  penis  is  raised — e.g.^ 

48 


THE  ANATOMY  OF  THE  UKETHRA  49 

during  erection.     The  urethra  then  only  has  one  curve,  the  concavity  of 
which  is  directed  forwards  and  upwards. 

Its  Different  Parts. — Examination  of  a  median  vertical  section  of  the 
pelvis  shows  that  the  most  posterior  portion  of  the  urethra  is  almost  com- 
pletely surrounded  by  the  prostate  gland.  Below  the  prostate  the  channel 
is  free  for  about  10  to  12  millimetres,  and  perforates  the  middle  aponeurosis 
of  the  perineum.  Farther  forward  the  urethra  enters  the  upper  surface  of 
a  column  of  erectile  tissue,  which  forms  a  protecting  sheath  for  it.  This 
structure  is  termed  the  "  corpus  spongiosum  " ;  the  urethra  runs  in  it  up  to 
its  termination.  Owing  to  this  anatomical  arrangement,  the  urethra  can 
be  divided  into  three  portions :  a  prostatic,  a  membranous,  and  a  spongy 
portion. 

Anterior  and  Posterior  Urethra. — For  clinical  and  pathological  purposes — 
which  are  alone  of  importance  to  us — the  spongy  portion,  which  extends 
from  the  tip  of  the  penis  to  the  inferior  part  of  the  perineum,  is  usually  called 
the  anterior  urethra.  The  remainder,  comprising  the  prostatic  and  mem- 
branous portions,  is  the  posterior  urethra.  This  terminology  is  due  to  Gruyon, 
who  established  its  clinical  importance. 

For  practical  purposes  we  thus  recognize  two  parts,  which  are  separated 
from  each  other  at  the  membranous  portion:  an  anterior  urethra,  com- 
prising the  canal  in  front  of  the  membranous  sphincter;  and  a  posterior 
urethra,  comprising  the  part  behind  the  sphincter. 

This  distinction  is  based  upon  anatomical,  physiological,  and  develop- 
mental considerations.  Picard,  in  1885,  and  others  have  shown  that  the 
posterior  urethra  is  formed  solely  from  the  genito-urinary  sinus,  whilst  the 
anterior  urethra  is  derived  from  a  long  bud  which  is  an  offshoot  from  the 
anterior  wall  of  the  cloaca.  This  "  anlage  "  gradually  develops  into  a  long 
gutter  which  finally  closes,  and  thus  forms  the  anterior  urethra. 

The  membranous  sphincter  thus  forms  the  barrier  between  the  anterior 
urethra,  which  is  in  free  communication  with  the  outside,  and  the  posterior 
urethra,  of  which  the  secretions  readily  flow  back  into  the  bladder. 

It  has  been  shown  on  an  endless  number  of  occasions  that  liquids  which 
are  injected  under  moderate  pressure  into  the  anterior  urethra  by  means 
of  an  ordinary  syringe  do  not  travel  beyond  the  bulb,  and  that  a  considerable 
pressure  is  required  to  force  the  barrier  formed  by  the  membranous  sphincter. 

Thus,  all  secretions  formed  in  front  of  the  sphincter  flow  out  of  the 
urethra  through  the  meatus,  whilst  those  of  the  posterior  urethra  regurgitate 
into  the  bladder. 

Lumen  of  the  Urethra. — The  lumen  of  the  urethra  varies  in  its  different 
parts. 

The  meatus  is  situated  at  the  tip  of  the  glans,  and  is  formed  by  two  lateral 
lips  which  are  joined  by  two  commissures — an  inferior  and  a  superior. 

4 


50 


GONOKRHEA 


These  commissures  are  often  membranous,  either  in  their  upper  or  in  their 
lower  portions.^ 

Normally,  the  meatus  is  directed  forwards,  but  it  is,  perhaps,  more  often 
found  to  be  directed  slightly  downwards.  Its  shape  varies  with  different 
individuals,  so  much  so  that  it  is  impossible  to  describe  a  typically  normal 
shape. 


12. 


Fig.  8. — The  Male  Urethra,  seen  in  a  Median  Vertical  Section  through 
THE  Body.     (After  L.  Testut.) 

1,  Symphysis  pubis;  2,  pre-vesical  space;  3,  abdominal  wall;  4,  bladder;  5,  urachus: 
6,  §eminal  vesicle  and  vas  deferens;  7,  prostate;  8,  Santorini's  venous  plexus; 
9,  sphincter  of  the  bladder ;  10,  suspensory  ligament  of  the  penis ;  11,  flaccid  penis ; 
12,  penis  during  erection;  13,  glans;  14,  bulb  of  the  urethra;  15,  cul-de-sac  of  the 
bulb. 

a,  Prostatic  urethra ;  h,  membranous  urethra ;  c,  spongy  urethra. 

Not  infrequently  the  meatus  has  several  orifices,  of  which  the  upper  one 
(or  ones)  is  usually  imperforate.  The  lowest  of  these  openings  is  always 
the  most  important ;  it  is  the  one  which  constitutes  the  orifice  of  the  urethra. 
In  all  cases  of  this  kind  a  more  or  less  marked  degree  of  hypospadias  is 
present. 

The  meatus  is  the  narrowest  and  the  least  extensible  portion  of  the 

1  Pasteau,  "  Les  Differentes  Formes  du  Meat  Urina'ire  chez  I'Homme,"  Annal.  des 
Mai.  Genito-Urin.,  April,  1897. 


THE  ANATOMY  OF  THE  UKETHRA 


51 


—  3 


urethra.  In  a  healthy  organ  it  is  therefore  the  most  difficult  part  to 
overcome.  Hence  it  becomes  necessary  in  many  cases  to  split  the 
meatus  in  order  to  be  able  to  introduce  a  sound  of  sufficient  size ;  or, 
at  any  rate,  one  has  to  resort  to  a  temporary  dilatation  of  the  meatus  with 
appropriate  instruments.  It  should,  however,  be  remembered  that  it 
is  impossible  to  widen  the  lumen  of  the  meatus  to  any  marked  degree  by 
mere  dilatation. 

Immediately  behind  the  meatal  narrowing  the  lumen  of  the  urethra 
widens  out  into  the  fossa  navicularis,  which  is  about  20  to  2  o  millimetres  long, 
and  is  limited  behind  by  the 
necJc  of  the  fossa  navicularis.  At 
this  second  narrowing  a  sound 
is  again  apt  to  stop.  This 
arrangement  is  therefore  not 
without  practical  importance, 
and  it  is  advisable,  in  cases  of 
congenital  atresia  of  the  meatus, 
not  only  to  open  this  structure 
by  meatotomy,  but  also  to  in- 
clude the  fossa  navicularis  and 
its  neck  in  the  operation. 

The  cavernous  portion  is 
uniform  and  cylindrical,  and 
has,  for  practical  purposes,  the 
same  width  in  its  entire  length. 

It  ends  in  a  fusiform  enlarge- 
ment— ^the  hulb — which  is  the 
widest  part  of  the  urethra.  In 
it  instruments  which  so  far 
fitted  the  urethral  walls  tightly, 
lose  all  contact  with  them. 

The  wide  bulbous  portion  is 
limited  behind  by  the  mem- 
branous isthmus.  The  lumen 
of  the  membranous  portion  is 
practically  uniform. 

Once  the  urethra  has  passed  the  uro-genital  diaphragm,  it  widens  out 
into  another  fusiform  enlargement.  The  greatest  width  of  this  enlargement 
is  situated  at  the  level  of  the  verumontanum.  The  urethra  then  becomes 
narrower  again,  a  further  constriction  being  found  immediately  in  front  of 
the  opening  of  the  bladder. 

To  resume  :   The  urethra  presents  four  narrow  points:  (1)  The  meatus; 


Fig.  9. — The  Lumen  of  the  Ubethba,  seen 
IN  A  Sagittal  Section. 

(After  L.  Testut.) 

1,  Bladder;  2,  cul-de-sac  of  the  bulb;  3,  neck 
of    the    bladder ;    4,   prostatic    widenmg ; 

5,  narrowmg  at  the  membranous  portion; 

6,  neck  of  the  bulb;  7,  penile  narrowing; 
8,  fossa  navicularis ;  9,  meatus. 


52 


GONORRHEA 


14 

CROULEflAS 


Fig.  10. — The  Prostate  in  Sagittal  Section.  Section  through  a  Congealed 
Subject,  passing  slightly  to  the  Left  of  the  Middle  Line;  the  Figure 
SHOWS  the  Right  Half  of  the  Section.     (After  L.  Testut.) 

1,  Symphysis  pubis;  2,  bladder,  with  its  neck  2';  3,  anterior  ligament  of  the  bladder;. 
4,  umbilico-prevesical fascia  of  Faraboeuf ;  5,  prevesical  space ;  6,  rectum;  7,  recto- 
vesical fold  of  peritoneum,  containing  a  loop  of  small  intestine;  8,  prostate;  9,  veru- 
montanum ;  10,  left  ejaculatory  duct  cut  obliquely ;  1 1,  right  vas  deferens ;  12,  middle 
aponeurosis  of  the  perineum,  with  Guthrie's  muscle;  13,  prostato-peritoneal fascia ;. 
14,  anus;  15,  external  sphincter  of  the  rectum;  16,  Cowper's  gland;  17,  bulb  of  the 
urethra;  18,  spongy  urethra;  19,  corpus  cavernosum;  20,  suspensory  ligament  of 
the  penis;  21,  deep  dorsal  vein  of  the  penis;  22,  Santorini's  venous  plexus;. 
23,  perineum;  24,  scrotum. 


(2)  the  far  end,  or  neck,  of  the  fossa  navicularis ;  (3)  the  membranous  isthmus ;. 
(4)  the  vesical  orifice.  To  these  constrictions  correspond  five  fusiform 
enlargements:  (1)  The  fossa  navicularis;  (2)  the  cavernous  portion;  (3)  the 
bulb;  (4)  the  membranous  portion;  (5)  the  prostatic  portion. 

Of  the  four  narrow  points,  the  first  two  are  the  most  inelastic;  the  two- 


THE  ANATOMY  OF  THE  URETHRA 


53 


latter  are  easily  dilated.     Of  the  five  spindles,  the  first  one  is  only  slightly 
dilatable,  whilst  the  third  can  be  widened  with  the  greatest  ease. 

Length. — In  the  adult  the  urethra  measures  about  16  centimetres,  of 
which  2-5  belong  to  the  prostatic  portion,  1-5  to  the  membranous,  and 
12-0  to  the  spongy. 


Fig.  11.— The  Urethra  opened  AiiONG  its  Upper 
Surface,  and  spread  out  in  Order  to  show 
THE  Details  of  its  Inferior  and  Lateral 
Surfaces.     (After  L.  Testut.) 

A,    Prostatic    portion  ;    B,   membranous    portion  ; 
C,  spongy  portion. 

1,  Verumontanum,  with  the  orifices  of  the  ejaculatory 
ducts;  2,  frenum of  the  verumontanum;  3,  pros- 
tate, with,  3',  the  prostatic  glandules  situated  on 
the  an tero -superior  aspect  of  the  urethra;  4,  sec- 
tion through  the  unstriped  sphincter;  5,  section 
through  the  striped  sphincter ;  6,  wall  of  the  mem- 
branous portion ;  7,  Cowper's  glands,  with,  7',  the 
orifices  of  their  ducts;  8,  bulb;  9,  longitudinal 
folds  of  the  bulbous  and  membranous  portions  of 
the  urethra ;  10,  posterior  wall  of  the  spongy  ure- 
thra; 11,  roots  of  the  corpora  cavernosa;  12,  sep- 
tum between  the  corpora  cavernosa,  along  which 
the  urethra  has  been  opened;  12',  orifice,  or 
lacuna,  through  which  the  meshes  of  the  two  cor- 
pora cavernosa  intercommunicate;  13,  termina- 
tion of  the  corpus  cavernosum  m  an  excavation  in 
the  glans;  13',  fibrous  septum  separating  corpus 
cavernosum  from  glans ;  14,  section  through  the 
anterior  partof  the  corpus  cavernosum;  15,  glans ; 
16,  fossa  navicularis,  with,  17,  the  two  halves 
of  Guerin's  valve;  18,  lacmise  of  Morgagni; 
19,  meatus. 

Outer  Aspect  and  Relations. — 1.  Prostatic 
Urethra. — The  prostatic  urethra  begins  im- 
mediately at  the  neck  of  the  bladder,  and 
traverses  the  substance  of  the  prostate 
gland  at  the  junction  of  its  anterior  one-fifth  with  its  posterior  four- 
fifbhs. 

The  prostatic  urethra  is  in  relation  :  in  front,  with  the  venous  plexus  of 
Santorini  and  the  symphysis  pubis ;  on  each  side,  with  the  fascia  covering 
the  levator  ani  muscle  and  the  levator  ani ;  behind,  with  the  rectum  and  the 
prostato-peritoneal  fascia  of  DenonvilHers.  The  two  ejaculatory  ducts 
enter  the  prostatic  urethra  from  behind. 


54 


GONOREHEA 


Above,  the  prostatic  portion  is  directly  continuous  witli  the  neck  of  the 
bladder,  and  below,  it  joins  the  membranous  urethra. 

2.  Membranous  Urethra. — The  membranous  urethra  passes  through  the 
middle  perineal  aponeurosis,  which  adheres  to  its  walls.  This  aponeurosis 
is  thus  one  of  its  means  of  fixation. 

The  relations  of  this  portion  are  :  in  front,  the  symphysis  pubis;  behind, 
the  rectum.  Above,  it  is  continuous  with  the  prostatic  portion,  and  below, 
it  unites  with  the  bulb.     The  membranous  urethra  is  close  to  the  skin, 

from  which  it  is  separated  by  unimpor- 
tant structures  only.  It  was  for  this 
reason  that  surgeons  used  to  approach 
the  bladder  through  it  in  former  days. 
3.  Spongy  Urethra.  —  The  spongy 
urethra  is  surrounded  in  almost  its 
entire  length  by  an  erectile  sheath,  the 
"  corpus  spongiosum,"  from  which  its 
name  is  derived.  It  runs  in  an  angular 
groove  formed  by  the  apposition  of 
the  two  corpora  cavernosa.  At  its 
posterior  extremity  the  corpus  spongio- 
sum expands  to  form  a  bulb;  in  front, 
it  swells  out  into  the  glans. 

This  portion  of  the  urethra  is  the 
longest,  and  may  be  divided  into  a 
ferineal,  scrotal,  penile,  and  balanic  part 
for  purposes  of  description. 

The  perineo-scrotal  portion  is  in 
relation  laterally  with  the  two  ischio- 
pubic  rami,  which  are  each  covered 
by  their  corpus  cavernosum  and  the 
corresponding  ischio-cavernosus  mus- 
cle. It  is  accompanied  by  the  secretory 
ducts  of  Cowper's  glands.  Below,  the 
spongy  urethra  is  covered  by  skin,  subcutaneous  tissue,  the  superficial  fascia 
of  the  perineum,  and  the  bulbo-cavernosus  muscle. 

The  penile  part  occupies  the  inferior  aspect  of  the  penis. 
Inner  Aspect. — The  interior  of  the  urethra  varies  in  its  different  portions, 
which  therefore  are  described  separately. 

1.  Prostatic  Urethra. — On  the  posterior  wall  of  the  prostatic  urethra  is 
an  oblong  elevation  which  occupies  its  middle.  This  structure  is  always 
well  marked,  and  is  called  the  verumontanum. 

The  verumontanum  is  usually  12  to  14  millimetres  long  and  1  millimetre 


Fig.  12. — Front  View  of  the  Veru- 
montanum. (The  Inferior  Wall 
OF     THE      Urethra      has      been 

STRAIGHTENED   OUT.) 

(After  L.  Testut.) 

1,  Bladder;  2,  urethra;  3,  prostate; 
4  verumontanum;  5,  frenum  of  the 
verumontanum;    6,    urethral    crest; 

7,  utriculus,    or    sinus     pocularis; 

8,  orifices  of  the  ejaculatory  ducts ; 

9,  prostatic  fossette;  10,  openings  of 
the  prostatic  glands  (prostatic  sinus). 


THE  ANATOMY  OF  THE  URETHRA  55 

broad.  Its  posterior  end  terminates  by  a  number  of  folds  which  run  back 
to  the  vesical  orifice,  and  form  the  frenum  of  the  verumontanum. 

Behind  the  verumontanum  one  usually  finds  a  more  or  less  marked  de- 
pression; this  is  the  'prostatic  fossette,  into  which  the  ducts  of  the  middle  lobe 
of  the  prostate  open  {vide  Chapter  VIII.). 

The  anterior  extremity  of  the  verumontanum  is  prolonged  forwards  by  a 
fold,  called  the  urethral  crest,  which  ends  in  the  membranous  urethra  after 
bifurcation. 

The  base  of  the  verumontanum  forms  part  of  the  urethral  wall,  from 
which  it  is  an  offshoot. 

Its  apex  presents  a  slit  running  in  an  antero-posterior  direction,  which 
occupies  the  middle  line,  and  leads  to  a  small  cul-de-sac — ^the  prostatic 


Fig.  13. — Transverse  Sections  through  the  Verumontanum  :  A,  Through  the 
Highest  Portion,  behind  the  Chief  Excretory  Ducts  of  the  Prostate; 
B,  Immediately  Above  the  Orifices  of  the  Utriculus  and  the  Orifices  of 
the  Ejaculatory  Ducts;  C,  Below,  and  in  Front  of,  the  Orifices  of  the 
Ejaculatory  Ducts.     (After  Henle,  modified,  from  L.  Testut.) 

I,  Central  column  of  the  verumontanum;  2,  cavernous  tissue;    3,  urethral  mucous 
membrane;  4,  utriculus;  5,  5',  ejaculatory  ducts. 

utriculus,  or  sinus  pocularis.  This  utriculus  is  developed  from  the  inferior 
extremity  of  Miiller's  ducts,  and  therefore  represents  embryologically  the 
male  vagina,  and  not  the  male  uterus,  as  "Weber  taught.  To  the  right  and 
left  of  the  utriculus  are  the  openings  of  the  ejaculatory  ducts,  which  pour 
the  sperma  into  the  urethra. 

On  each  side,  the  verumontanum  is  limited  by  a  depression  running 
in  an  antero-posterior  direction.  These  lateral  grooves  of  the  verumonta- 
num contain  a  number  of  openings  for  the  bulk  of  the  prostatic  gland 
ducts. 

Structure  of  the  Verumontanum. — The  verumontanum  is  composed  of 
erectile  tissue  which  is  supported  by  a  central  column  of  elastic  and  muscular 
tissue.     It  is  covered  in  by  the  urethral  mucous  membrane,  which  shows  at 


56 


GONOEKHEA 


its  level  a  few  fine  folds,  thus  allowing  for  adaptation  to  variations  in  the 

volume  of  the  verumontanum. 

The  latter,  which  is  traversed  by  the  ejaculatory  ducts,  is  an  erectile 

organ.     It  becomes  turgid  during  erection,  and  thus  causes  the  ejaculatory 

orifices  to  gape.  At  the  same  time  it  shuts  ofi 
the  part  in  immediate  proximity  of  the  bladder, 
and  thus  plays  an  important  role  in  preventing 
the  flow  of  urine,  or  micturition,  during  erection. 

2.  Membranous  Urethra. — The  membranous 
urethra  presents,  normally,  on  its  inferior  wall  a 
series  of  longitudinal  folds  which  continue  the 
urethral  crest,  and  are  finally  lost  in  the  cul-de-sac 
of  the  bulb.  On  its  walls  the  openings  of  Littre's 
glands  are  visible. 

3.  Spongy  Urethra. — In  the  spongy  urethra 
we  find — 

(1)  The  Orifices  of  Cowper's  Glands. — They  are 
two  in  number,  and  are  situated  on  the  inferior 
wall,  to  each  side  of  the  middle  line  in  the  lower 
part  of  the  bulb. 

(2)  The  LacuncB  of  Morgagni.  —  They  were 
discovered  by  Morgagni  in  1706.  They  are 
arranged  in  linear  series,  and  are  of  various  sizes. 
Morgagni  described  large  ones,  or  foramina,  and 
small  ones,  or  foraminula.  Sappey  added  an 
intermediate  type.  The  large  ones  are  found 
along  the  middle  line  on  the  upper  surface.  They 
are  constant.  The  intermediate  and  small  ones 
are  usually  on  the  lateral  surfaces.  As  a  rule 
there  is  no  lacuna  on  the  lower  surface.  The  small 
lacunse  are  only  a  few  millimetres  deep ;  the  large 
ones  extend  often  for  a  considerable  distance  (6 
to  7  millimetres)  submucously.  Their  fundus  is 
directed  backwards  towards  the  bladder,  and  is 
usually  simple;  but  sometimes  one  meets  with  a 
double  or  triple  pouch. 

One  lacuna,  which  is  practically  constant,  is 
situated  1  to  2  centimetres  behind  the  meatus.  It  is  larger  than  the  others, 
and  has  been  specially  described  by  Guerin;  hence  the  name  valve  of 
Guerin  for  the  fold  of  mucous  membrane,  and  sinus  of  Guerin  for  the  pouch 
formed  by  it. 

In  the  course  of  my  personal  researches  on  the  anatomy  of  the  normal 


Fig.  14.  —  The  Ubethba, 
opened  in  the  middle 
Line  along  its  Inferior 
Surface,  in  Order  to 
SHOW  THE  Details  of 
ITS  Upper  Wall. 

(Partly  after  Jarjavay.) 

1,  Upper  angle  of  meatus, 
with,    1',    its     right    lip; 

2,  fossa     navicularis; 

3,  probe  entering  the  sinus 
of  Guerin;  4,  lateral  bor- 
ders of  the  urethra,  with, 
4',  the  lateral  foraminula ; 
4",  median  foramina; 
5,  large  lacunae  of  Mor- 
gagni, or  foramina;  6,  sec- 
tion through  the  corpus 
spongiosum ;  7,  prepuce 
drawn  back;  8,  section 
through  the  integuments ; 
9,  glans. 


THE  ANATOMY  OF  THE  URETHRA 


57 


urethral  mucous  membrane,  I  have  been  struck  by  the  number  and  by  the 
importance  of  Morgagni's  lacunce.  These  little  pouches,  which  are  entirely 
formed  by  invaginations  of  the  mucosa,  are  of  variable  depth.  The  deepest 
and  most  constant  one  is  GuerirCs  valve,  which  is  situated  in  the  balanic 
portion,  about  1  to  2  centimetres  from  the  meatus.  If  one  spreads  out  a 
urethra,  after  having  slit  it  up  on  its  under  surface  along  the  middle  line, 
these  lacunae  become  easily  accessible,  and  can  be  explored  with  a  probe. 
One  often  finds,  then,  not  only  one  large  lacuna,  but  as  many  as  three,  or 
even  four,  in  the  penile  region,  and  all 
of  them  are  similar  in  structure  and 
size  to  Guerin's  valve. 

Fig.  15,  which  has  been  drawn 
from  nature,  shows  the  anatomical 
disposition  in  a  man  of  forty-five  ; 
small  quantities  of  suet  were  injected 
into  the  lacunae  in  order  to  show  their 
size  and  how  they  gape. 

I  have  investigated  fourteen  cases, 
varying  in  age  from  seventeen  to 
seventy-five  years.  Only  one  of  them 
(a  man  of  fifty-five)  had  a  completely 
smooth  mucosa  and  no  lacunse.  In  one 
case  only  a  solitary  lacuna  was  present, 
which  was  situated  in  the  middle  of  the 
penile,  and  not  in  the  balanic  part  (man 
of  sixty-eight). 

On  four  occasions  two  large  lacunae 
were  found — one  in  the  balanic  part 
(Gruerin's  valve),  and  one  in  the  penile 
(men  of  thirty-four,  forty-five,  forty- 
eight,  fifty). 

Three  valves  were  found  six  times, 
one   of  them  in   the    balanic    portion 
(Guerin's  valve),  and  the  two  others  in  a  row  in  the  penile  part  (men  of  seven- 
teen, twenty-eight,  thirty-nine,  fifty-four,  sixty,  sixty-five). 

Two  cases  had  four  valves  spread  along  the  penile  urethra  (men  of  fifty- 
eight  and  seventy-five). 

The  depth  of  these  lacunae  varied  from  5  to  12  millimetres.  They  are, 
however,  sometimes  still  larger;  Cruveilher,  for  instance,  met  with  some 
which  were  27  millimetres  deep. 

At  all  events,  the  structure  of  these  lacunae,  which  reminds  one  of  a 
pigeon's  nest,  is  responsible  for  the  important  role  which  they  play  both  in 


Fig.  15. — Longititdin-al  Section  of 
THE  Penis. 

Normal  aspect  of  the  upper  surface  of 
the  penile  urethra,  with  its  lacunae 
of  Morgagni  and  Littre's  glands. 


58  GONOERHEA 

acute  and  chronic  gonorrhea.  They  are  regular  hampers  in  the  bottom  of 
which  the  gonococcus  can  live  for  a  long  time,  and  in  which  the  organism 
is  sheltered  against  irrigations  or  injections.  The  fluid  simply  passes  over 
these  lacunee,  but  does  not  enter  them. 

When,  during  an  attack  of  gonorrhea,  a  lacuna  or  a  group  of  Littre's 
glands  becomes  infected,  the  inflammation  leads  to  their  obstruction. .  As 
has  been  well  shown  by  Keersmaecker  and  Verhoogen,^  the  mouths  of  these 
glands,  or  the  orifice  of  the  lacuna,  are  gradually  obliterated,  and  thus  the 
gonococci  are  shut  off.  A  regular  little  cyst  is  formed  as  the  gland  expands. 
This  cyst  may  either  remain  closed  or  it  may  burst  partially  into  the  urethra. 
In  both  instances  it  remains  a  hotbed  for  germs,  in  which  they  are  not  dis- 
turbed by  any  irrigations  or  injections. 

Histologically  there  is  no  difference  between  the  walls  of  these  lacunse 
and  the  urethral  mucosa.  They  are  not  true  glands,  but  merely  depressions 
in  the  latter. 

HISTOLOGY  OF  THE  URETHRA. 

The  walls  of  the  urethra  are  formed  by  three  concentric  coats,  which  are, 
from  without  inwards  : 

1.  The  muscular  coat. 

2.  The  vascular  coat. 

3.  The  mucous  coat. 

1.  Muscular  Coat. — The  muscular  coat  is  composed  of  unstriped  muscle 
fibres  which  are  arranged  in  two  layers — an  internal  longitudinal  one,  and 
an  external,  which  is  circular.  The  longitudinal  fibres  are  the  continuation 
of  the  plexiform  layer  of  the  musculature  of  the  bladder;  they  are  well 
marked  in  the  prostatic  region,  and  gradually  become  fewer  and  fewer, 
there  being  less  in  the  membranous  portion,  and  still  less  in  the  spongy  part. 
The  circular  fibres  are  well  developed  in  the  posterior  urethra,  which  they  sur- 
round at  its  commencement,  forming  a  large  ring — the  unstriped  s'phincter  of 
the  bladder.  In  the  normal  state  this  sphincter  keeps  the  bladder  closed,  owing 
to  its  tonic  contraction.  It  also  occludes  the  part  of  the  urethra  behind  the 
ejaculatory  ducts,  and  thus  compels  the  sperma  to  travel  down  the  urethra 
instead  of  flowing  back  into  the  bladder.  Apart  from  these  unstriped  fibres, 
there  are  a  number  of  muscles  of  voluntary  contraction:  the  bulbo-cavernosus^ 
Guthrie's  muscle,  Wilson's  muscle,  and  the  sphincter  urethrse. 

2.  Vascular  Coat. — This  layer  is  thin,  and  ill-defined  in  the  prostatic  and 
membranous  portions.  It  is,  however,  well  marked  in  the  spongy  urethra, 
where  it  forms  a  kind  of  bed  for  this  latter  structure.  This  vascular  forma- 
tion— ^the  corpus  sjyongiosum — ^is  analogous  to  the  corpora  cavernosa,  and 

1  De  Keersmaecker  and  Verhoogen,  L'Urethrite  Chronique  d'Origine  Gonococcique, 
Bruxelles,  1898. 


THE  ANATOMY  OF  THE  URETHRA 


59 


participates  in  the  phenomenon  of  erection.  Histologically,  it  is  composed 
of  numerous  venous  cavities  which  vary  in  size,  and  anastomose  freely. 

3.  Mucous  Coat. — The  urethral  mucosa  lines  the  canal  in  its  whole 
course.  During  life  its  colour  is  uniformly  red,  as  can  iDe  easily  seen  by 
means  of  the  urethroscope. 

G-enerally  speaking,  the  mucosa  is  smooth  and  presents  a  uniform 
lustre.  It  is  rather  thin  and  soft,  despite  its  great  elasticity.  It  is  thus 
capable  of  resisting  traction  and  distension  well,  but  it  is  easily  damaged  and 
perforated  by  a  metal  instrument. 

It  presents,  for  descriptive  purposes  : 

A.  A  structure  of  its  own. 

B.  A  system  of  glands  connected  with  it. 


A.  Structure  of  the  Urethral  Mucous  Membrajste. 

Thickness. — The  thickness  of  the  urethral  mucosa  varies  shghtly  in  its 
difierent  parts.  It  is  comparatively  thick  in  the  prostatic  portion — 
0-3  millimetre — and  tapers 
in  the  membranous  portion 
to  0'2  millimetre. 

Histology.  —  Two  layers 
can  be  made  out : 

1.  An  epithelial  layer,  60 
to  80  fjL  thick,  which  is  com- 
posed in  its  most  superficial 
part  by  two  rows  of  cylin- 
drical cells.  The  deeper  part 
is  formed  by  replacement 
cells,  which  are  polygonal  or 
ovoid. 

2.  A  connective  -  tissue 
layer,  or  stroma,  which  con- 
sists of  a  tough  laminar 
connective  tissue,  containing 
a  great  number  of  elastic 
fibres.  These  elastic  fibres 
form  a  network  which  pro- 
jects between  the  muscular 
fibres,  and  extends  into  the  meshes  of  the  erectile  tissue.  This  arrangement 
strengthens  the  mucosa,  and  prevents  the  different  layers  from  separating. 
In  the  region  of  the  glans  the  stroma  shows  well-developed  papillae;  behind 
the  fossa  navicularis  these  papillse  are  rudimentary. 


Fig.  16. — Histologicax,  Aspect  of  the  Urethral 
Mucous  Membraxe  (400  Diameters  ). 

(After  Lichtenberg. ) 

G,  Glandular  sinus ;  L,  leucocytes  penetrating  ir.to 
the  mucosa. 


60  GONOEKHEA 

B.  The  Glandular  Apparatus  op  the  Urethral  Mucous  Membrane. 

In  early  embryonic  life  the  urethral  mucous  membrane  is  quite  smooth. 
About  the  third  month  of  intra-uterine  existence  solid  epithelial  buds  are 
formed  on  the  deep  surface  of  the  epithelial  layer,  and  penetrate  into  the 
stroma,  thus  giving  rise  to  various  glands,  which  may  be  grouped  under 
three  headings: 

1.  The  glands  of  the  anterior,  cavernous 

portion  of  the  urethra. 

2.  The  prostate  gland. 

3.  Cowper's  glands. 

The  urethra  is  thus  well  suppHed  with  glands,  which  are  destined  to 
lubricate  the  epithelium,  and  to  protect  it,  by  means  of  their  secretions, 
against  the  irritant  effect  of  the  urine.  A  copious  flow  of  the  mucus  which 
they  produce  takes  place  during  erection. 

1.  The  Glands  of  the  Anterior,  Cavernous  Portion  of  the  Urethra. 

These  glands  are  of  three  different  types,  which  have  been  well  studied 
by  Lichtenberg  of  Heidelberg  •} 

1.  Tubo- Alveolar  Subepithelial  Glands. — These  glands  are  deeply  sunk 
into  the  tissues,  and  are  fixed  between  the  meshes  of  the  corpus  spongiosum. 
Their  young  forms  are  often  intra-epithelial,  and  communicate  with  the 
lumen  of  the  urethra  by  a  very  narrow  duct.  Most  authors  classify  them  as 
cysts,  and  one  finds  them  described  in  the  literature  as  "  follicles."  They 
are  usually  considered  to  consist  of  degenerated  epithelium  which  has  been 
separated  off  from  the  lumen  of  the  urethra. 

Lichtenberg  holds  that  they  are  progressive  formations  which  are  free 
during  the  stage  of  development  in  the  deep  part  of  the  epithelium,  but 
remain  small  and  keep  in  contact  with  the  epithelium — hence  their  sub- 
epithelial position.  Occasionally  they  increase  to  such  an  extent  that 
they  rise  to  the  level  of  the  mucous  membrane,  and  then  they  communicate 
freely  with  its  lumen.     They  represent  imperfect  glands  of  Littre. 

2.  Depressions  of  Glandular  Shape.— Their  structure  is  irregular.  They  are 
covered  by  an  epithelium  which  is  similar  to  that  of  the  former  group,  but  they 
are  more  developed,  and  exist  as  true  mucous  glands  in  other  vertebrates. 

3.  Submucous  Glands. — These  glands  are  superficial,  and  bulge  into  the 
submucous  part  of  the  mucosa.  They  are  visible  if  one  examines  the  mucous 
membrane  with  a  lens.  In  the  spongy  part  they  are  noteworthy  on  account 
of  their  situation;  they  are  partly  covered  in  by  muscle  fibres.    Littre  was 

1  Lichtenberg,  Beitrdge  zur  Histologie,  Mikroshopischen  Anatomic,  und  EntwicUungs- 
gescMchte  des  Urogenital  Kanals  de  Mannes  und  seiner  Druesen,  Wiesbaden,  1906. 


THE  ANATOMY  OF  THE  URETHRA 


61 


the  first  to  describe  them,  in  1706.  As  their  orifices  are  in  the  midst  of  erec- 
tile tissue,  they  secrete  a  considerable  amount  of  mucus  during  erection. 

In  the  prostatic  portion  Littre's  glands  are  few  and  rudimentary.  They 
are  scattered  in  the  membranous  urethra,  and  present  in  great  numbers 
in  the  spongy.  They  occupy  chiefly  the  upper  and  lateral  surfaces.  On 
the  lower  surface  there  are  but  very  few.  Their  ducts,  which  vary  in  length 
according  to  the  more  or  less  superficial  position  of  the  glands,  open  either 
directly  on  the  surface  of  the  mucous  membrane  or  into  the  pouches  of  the 
lacunae  of  Morgagni, 

Histologically,  they  are  composed  of  a  thin  membrane  and  a  prismatic 
epithelium.      They  secrete  a  clear,  transparent  mucus  which  reaches  the 


Fig.  17. — Histological  Aspect  of  the  Urethral  Mucosa  in  the  Cavernoits 
Region  (155  Diameters).     (After  Lichtenberg.) 

E,  Epithelial  cells :  L,  leucocytes  entering  the  mucosa ;  G,  glandular  sinus  ; 

V,  bloodvessels. 


urethra  through  their  ducts.  The  latter  are  directed  obliquely  towards  the 
meatus,  and  vary  in  length  from  a  few  millimetres  to  2  centimetres.  Ob- 
struction of  a  duct  is  sufficient  to  form  within  the  urethral  wall  a  focus 
which  discharges  its  contents  only  on  and  off  into  the  urethra,  and  will  keep 
up  a  chronic  urethritis. 

These  glands  thus  are  of  considerable  importance.  When  infected,  they 
are,  together  with  the  lacunse  of  Morgagni,  hotbeds  for  micro-organisms. 
They  are  closed  by  a  plug  of  mucus,  and  discharge  their  contents 
intermittently  into  the  urethra.  The  organisms  within  them  defy  all 
irrigations,  injections,  and  instillations,  as  the  fluids  used  fail  to  reach 
these  recesses. 

It  is  thus  easily  understood  that  a  focus  of  this  nature  may  give  rise  to 


62 


GONORKHEA 


a  series  of  reinfections  which  drive  the  patient  and  his  surgeon  to  despair, 
and  to  repeated  recurrences,  even  when  a  properly-conducted  irrigation  treat- 
ment seemed  to  be  on  the  point  of  curing  the  discharge  from  the  urethra. 

2.  The  Prostate. 

The  prostate  is  a  gland  which  belongs  physiologically  to  the  sexual 
■organs.  It  is  conical  in  shape,  and  is  situated  just  below  the  bladder,  above 
the  middle  perineal  aponeurosis,  behind  the  symphysis  pubis,  and  in  front 
of  the  rectal  ampulla. 

Through  it  runs  the  urethra  from  above  downwards,  with  a  forward 
slope.     It  is  also  traversed  by  the  two  ejaculatory  ducts. 

Anatomically,  the  prostate  consists  of  two  lateral  lobes — a  right  and  a 
left  one — and  of  an  intermediate  portion — ^the  so-called  middle  lobe. 

9^ 


Fig.  18. — Histological  Aspect  of  the  Urethral  Mucous  Membrane  in  the 
Cavernous  Portion  (200  Diameters).     (After  LicMenberg.) 
G,  Glandular  sinus;  gl,  subepithelial  tubo-alveolar  glands;  V,  bloodvessels. 

Structure. — One  distinguishes  a  stroma  and  a  gland  substance.  The 
former  consists  of  a  mixture  of  connective  tissue  and  unstriped  muscle 
fibres.  Its  outer  surface  is  in  relation  with  the  walls  of  the  prostatic  fossa. 
Its  inner  surface  sends  out  septa  which  radiate  towards  the  centre  of  the 
organ,  where  they  form  a  mass  of  lesser  density — ^the  central  nucleus. 
Through  the  various  partitions  so  formed,  the  interior  is  divided  into  a 
number  of  small  spaces  which  are  occupied  by  the  glandular  substance. 

The  individual  prostatic  glands,  about  thirty  to  forty  in  number,  are 
arranged  in  a  radiating  fashion  around  the  urethra.  Their  excretory  ducts 
open  on  the  free  surface  of  the  urethral  mucous  membrane  by  small  round 
openings  which  are  readily  seen  with  a  magnifying-glass. 


THE  ANATOMY  OF  THE  URETHRA 


63 


The  glandular  elements  are  composed  of  a  dense  stroma  of  connective 
tissue  which  is  lined  with  the  secreting  epithelium. 

Under  normal  conditions  the  prostatic  secretion  is  only  excreted 
during  ejaculation,  and  mixes  immediately  with  the  sperma. 


3.  Cowper's  Glands. 

Cowper's  glands  are  small  round- 
ish masses  situated  behind  the  base 
of  the  bulb,  in  the  angular  space 
formed  by  it  and  the  membranous 
portion  of  the  urethra.  Their  size 
varies  from  that  of  a  bean  to  that  of 
a  small  hazelnut.  They  are  enclosed 
in  the  middle  aponeurosis  of  the 
perineum. 

Structure.  —  Cowper's  glands  be- 
long to  the  grape  type  of  glands,  and 
consist  of  lobules  and  acini.  The  walls 
of  the  latter  are  formed  by  a  single 
row  of  pyramidal  cells.  Their  excre- 
tory ducts  join,  and  form  one  single 


Fig.  19. —  The  Pbostatic  Utriculus, 
SEEN  IN  A  Sagittal  Section  through 
THE  Prostate.     (After  L.  Testut.) 

1,  Bladder,  with,  1',  its  neck;  2,  urethra; 
3,  prostate;  4,  verumontanum ;  5,  utric- 
ulus ;  6,  seminal  vesicle ;  7,  vas  deferens 
(a  probe,  introduced  into  this  duct,  is 
seen  to  appear  in  the  urethra  slightly 
to  the  outer  side  of  the  utriculus). 


Fig.  20.— The  Posterior  Part  op  the 
Urethra,  as  seen  after  a  Median 
Longitudinal  Incision  oe  its  Anterior 
Wall.     (After  L.  Testut.) 

1,  Neck  of  the  bladder;  2,  section  through 
prostate  and  urethral  sphincters ;  3,  sec- 
tion through  the  membranous  urethra; 
4,  section  through  the  spongy  urethra; 
4',  bulb ;  5  and  5',  the  two  corpora  caver- 
nosa; 6,  verumontanum,  with,  6',  the 
orifice  of  the  utriculus ;  7,  posterior  wall 
of  the  urethra ;  8,  ejaculatory  ducts,  with, 
8',  their  orifices;  9,  Cowper's  glands; 
10,  their  ducts  (dissected  out  on  the  right 
side);  10',  orifice  of  the  duct  of  Cowper's 
gland;  11,  longitudinal  folds  of  the  ure- 
thral mucosa;  12,  cul-de-sac  of  the  bulb; 
13,  neck  of  the  bulb. 


64 


GONOERHEA 


duct  which,  passes  through  the  inferior  layer  of  the  middle  aponeurosis  of 
the  perineum,  and  enters  the  substance  of  the  bulb.  In  this  way,  the 
duct  on  either  side  of  the  urethra  reaches  its  under-surface,  which  it  follows 
as  far  as  the  anterior  part  of  the  cul-de-sac  of  the  bulb.  Here  it  perforates 
the  urethra  and  opens  into  its  lumen.  Each  gland  of  Cowper  has  thus  a 
duct  of  relatively  considerable  length  (30  to  40  millimetres). 

The  secretion  of  Cowper's  glands  is  a  transparent,  viscous  fluid,  contain- 
ing albumin.  As  in  the  case  of  the  prostate  and  of  the  seminal  vesicles, 
these  glands  discharge  their  contents  at  the  time  of  ejaculation,  and  thus 
supply  the  sperma  with  one  of  its  elements. 


8      25 


18    16   19 

Fig.  21. — Sagittal  Section  through  a  Congealed  Subject  (Vikgin  of  Twenty- 
four,  Natural  Size),  comprising  the  Urethra,  the  Vulva,  and  the  Vagina. 
(After  L.  Testut.) 

1,  Symphysis  pubis;  2,  suspensory  ligament  of  the  clitoris;  3,  corpus  cavernosum 
clitoridis;  4,  anterior  extremity  of  the  clitoris  (glans);  5,  its  prepuce;  6,  dorsal  vein 
of  the  clitoris;  7,  intermediate  venous  plexus  between  clitoris  and  bulb;  8  and  8', 
anterior  and  posterior  walls  of  the  bladder;  9,  neck  of  the  bladder;  10,  urethra; 
11,  external  sphincter  of  the  urethra;  12,  urinary  meatus;  13,  labium  minus; 
14,  labium  ma  jus ;  15,  vestibule ;  16,  inferior  orifice  of  the  vagina ;  17  and  17',  anterior 
and  posterior  columns  of  the  vagina;  18,  vaginal  tubercle;  19, hymen;  20,  external 
sphincter  ani ;  20',  constrictor  cunni ;  21,  those  fibres  of  the  latter  muscle  which  are 
situated  between  urethra  and  clitoris;  22,  fossa  navicularis;  23,  fourchette; 
24,  vesico-uterine  fold  of  peritoneum;  25,  prevesical  space. 


THE  ANATOMY  OF  THE  URETHRA 


65 


II.  The  Female  Urethra. 

The  urethra  of  woman  is  much  shorter  than  the  male  urethra,  and  only 
has  one  function — namely,  to  act  as  a  channel  for  the  urine. 

Its  average  length  is  35  millimetres.  Its  width  is  generally  7  to  8  milli- 
metres ;  but  it  can  be  dilated  with  ease,  and  there  is  no  difficulty  in  passing 
sounds  10  or  12  milli- 
metres thick.  Certain 
surgeons,  like  Simon  of 
Heidelberg,  have  prac- 
tised dilatations  up  to 
20  millimetres,  and  Reli- 
quet  went  as  far  as  30 
millimetres. 

The  course  of  the 
female  urethra  is  directed 
obliquely  downwards  and 
forwards;  it  describes  a 
slight  curve,  the  con- 
cavity of  which  looks  up- 
wards and  forwards. 

Relations. — Behind, 
the  female  urethra  rests 
on  the  anterior   vaginal 


GDevy 


Fig.  22 

wail,  to  which  it  is  ad- 
herent. In  front  of  it  is 
the  venous  plexus  of 
Santorini,  the  constrictor 
cunni  muscle,  and  the 
symphysis  pubis. 

Its    lateral    relations 
are  the  venous  plexus  of 


■The  Feihale  Urethra,  seek  from  the 
Front.     (After  L.  Testut.) 

The  anterior  wall  of  the  urethra  has  been  incised 
along  the  middle  line,  and  the  urethra  has  been 
spread  out. 

1,  Bladder,  with  its  neck,  1';  2,  urethra,  with  its  longi- 
tudinal folds  and  glandular  orifices ;  3,  urethral  crest ; 
4,  muscular  coat  of  the  urethra ;  5,  external  sphincter 
of  the  urethra ;  6,  urinary  meatus ;  7,  vaginal  tubercle ; 
8,  vagina;  9,  labia  minora;  10,  clitoris,  with,  11,  its 
prepuce. 


Santorini,  Wilson's  mus- 
cle, the  middle  aponeurosis  of  the  perineum,  Gruthrie's  muscle,  the  constrictor 
cunni,  and  the  root  of  the  corpora  cavernosa  clitoridis. 

Its  upper  opening  corresponds  to  the  anterior  angle  of  the  trigone  of  the 
bladder.  Its  lower  orifice  is  the  urinary  meatus,  which  is  the  narrowest 
and  least  dilatable  part  of  the  canal.  It  is  placed  immediately  behind  the 
clitoris,  and  immediately  in  front  of  a  protrusion  called  the  "  vaginal 
tubercle,"  the  termination  of  the  anterior  column  of  the  vagina. 

Inner  Aspect. — A  certain  number  of  little  folds  run  along  the  urethra  from 
behind  forwards.     Apart  from  them,  the  urethral  mucous  membrane  pre- 

5 


66  GONOEEHEA 

sents  a  number  of  little  openings  which  correspond  partly  to  the  lacunae  of 
Morgagni,  and  partly  to  the  orifices  of  the  urethral  glands. 

Histology. — The  female  urethra  has  two  coats,  an  outer  muscular  coat, 
and  an  inner  mucous  coat.  The  former  is  composed  of  two  layers  of  un- 
striped  muscle  fibres.  The  longitudinal  muscle  fibres  are  just  external  to 
the  mucous  coat,  whilst  the  circular  ones,  which  are  the  more  superficial, 
form  in  the  region  of  the  neck  of  the  bladder  a  large  ring — the  unstriped 
sphincter.  This  musculature  is  reinforced  by  striped  fibres  which  form  the 
sphincter  of  voluntary  contraction. 

The  mucosa  consists  also  of  two  layers:  (1)  A  stroma,  containing  a 
great  number  of  elastic  fibres;  and  (2)  an  epithelium,  formed  by  two  or 
three  rows  of  polyhedrical  cells.  The  glands  are  less  numerous  than  in  the 
male,  and  are  nearly  all  located  in  the  anterior  portion.  The  region  in  the 
immediate  neighbourhood  of  the  sphincter  is  practically  free  from  glands. 

The  great  number  of  urethroscopic  examinations  which  I  have  carried 
out  on  women  has  shown  me  the  arrangement  just  described  to  be  constant. 
It  is  therefore  permissible,  from  this  point  of  view,  to  distinguish  an  anterior 
and  a  posterior  urethra,  just  as  in  the  case  of  man.  The  female  posterior 
urethra  is  essentially  muscular,  covered  by  a  smooth  mucous  membrane, 
whilst  the  anterior  one  is  essentially  glandular.  The  infection  of  its  glands 
by  the  gonococcus  is  the  chief  cause  of  the  long  duration  of  gonorrhea  in 
woman. 

THE  PATHOLOGY  OF  GONORRHEA. 

Before  describing  the  lesions  which  the  use  of  the  urethroscope  has 
allowed  us  to  discover  in  chronic  gonorrhea,  a  short  resume  of  our  present 
knowledge  of  its  pathology  may  here  be  given,  as  it  is  only  in  this  way  that 
these  lesions  can  be  understood. 

Histological  and  urethroscopical  researches  complete  each  other,  and 
they  should  go  hand  in  hand.  The  pathological  changes  in  chronic  urethritis 
are  clearly  visible  during  life  by  means  of  the  urethroscope,  but  they  become 
invisible  to  the  naked  eye  after  death,  because  the  local  congestion  and 
edema  vanishes  with  the  cessation  of  life. 

In  the  following  we  will  consider  the  infection  from  its  very  beginning, 
from  the  moment  the  gonococcus  enters  the  urethra  up  to  the  remotest 
lesions  which  it  produces. 

The  cases  of  acute  gonorrhea  in  which  a  post-mortem  examination  has 
been  made,  are  scarce.  Thanks  to  Finger,  who  inoculated  moribunds  with 
gonorrhea,  detailed  examinations  of  the  urethra  thirty-six  and  forty-eight 
hours  after  the  infection  have  been  made,  and  we  thus  have  an  account  of 
the  lesions  present  at  that  stage. 

Amongst  the  other  authors  who  have  studied  the  morbid  histology  of 


THE  PATHOLOGY  OF  GONORRHEA  67 

gonorrhea,  the  important  works  of  Dinklers  and  Finger,  Oberlander  and 
Neelsen,  Oberlander  and  Kollmann,  Baraban,  Wassermann  and  Halle, 
Bumm,  Tonton,  Jadassohn,  Fabry,  Rosinsky,  Wossidlo,  Motz,  and  others, 
should  be  mentioned.  These  researches  complete  each  other,  and  give  a 
complete  insight  into  the  activity  of  the  gonococcus  within  the  urethral 
mucous  membrane. 

The  Pathology  of  Acute  Urethritis. 

Once  the  gonococcus  has  fixed  itself  on  a  point  of  the  urethral  mucous 
membrane,  it  develops  on  the  surface  of  the  epithelial  layer.  After  a  very 
short  time,  however,  it  tends  to  enter  the  deeper  tissues.  In  the  case  of 
a  cylindrical  epithelium,  this  penetration  takes  place  readily,  less  so  if  the 
epithelium  is  of  the  flat  pavement  type.  The  cylindrical  epithelium  is  thus 
a  very  favourable  soil. 

This  fact  has  been  well  pointed  out  by  Finger,  and  it  explains  certain 
peculiarities  of  gonorrhea  infection. 

It  is  a  matter  of  common  knowledge — and  all  specialists  have  frequently 
occasion  to  corroborate  it — ^that  the  gonococci  penetrate  into  a  normal 
urethra  which  has  never  been  infected,  and  has  a  healthy  cylindrical  epi- 
thelium, much  more  easily  and  readily  than  into  one  which  has  been  infected 
some  time  or  other.     This  fact  explains  why  abortive  treatment  by  means 
of  immediate  irrigations  is  much  more  often  a  failure  in  fresh  cases  than  in 
subsequent  attacks.     One  of  the  consequences  of  gonorrheal  infection  of  the 
urethra  is  destruction  of  the  cylindrical  epithelium,  and  its  replacement  by 
pavement  epithelium.     After  a  couple  of  attacks,  the  urethra  has  undergone 
such  modifications  as  to  become  a  bad  soil  for  the  gonococcus.     The  organism 
finds  it  difficult  to  penetrate  into  the  epithehum,  and  thus  the  chances  of  a 
well-conducted  abortive  treatment  proving  successful  are  infinitely  greater. 
On  the  average,  thirty-six  hours  elapse  before  the  gonococcus  penetrates 
into  the  depth  of  the  urethral  mucosa.     This  period  during  which  the 
organism  remains  on  the  surface  is  free  from  symptoms,  and  is  termed  the 
incubation  'period.    When  the  gonococcus  enters  the  epithelium,  it  passes 
between  the  superficial  cells  wherever  there  is  least  resistance.     It  thus  ad- 
vances as  far  as  the  subepithelial  connective  tissue,  and  this  fact  is  of  the 
utmost  importance  therapeutically.     The  migration  of  the  gonococcus  is 
accompanied  by  an  intense  reaction  on  the  part  of  the  tissues,  which  finds 
its  expression  in  a  severe  inflammation  which  appears  usually  on  the  third 
day.     This  reaction  is  an  attempt  on  the  part  of  the  body  to  defend  itself 
against  the  invasion  by  a  pathogenic  irritant,  and  is  characterized  by  a 
pronounced  diapedesis  of  leucocytes.     These  cells  leave  in  large  numbers 
the  walls  of  their  capillaries,  which  are  dilated,  and  advance  towards  the 
cocci.     The  result  of  the  ensuing  struggle  is  the  purulent  discharge. 


68  GONOEEHEA 

To  schematize,  we  observe  tlie  following:  On  one  hand,  the  gonococci 
penetrate  into  the  mucous  membrane,  and  on  the  other  hand,  the  leucocytes 
leave  their  bloodvessels  and  attack  the  invaders.  In  the  struggle  which 
now  takes  place  within  the  mucosa,  the  white  cells  engulf  the  organisms; 
but  they  are  killed,  and  their  corpses,  laden  with  the  organisms,  are  brought 
to  the  surface  of  the  mucous  membrane,  and  discharged  into  the  lumen  of 
the  urethra,  thus  giving  rise  to  the  flow  of  pus  from  the  meatus. 

The  urethral  mucous  membrane  is  thus  a  true  battle-field,  and  it  will  be 
easily  seen  that  it  has  to  suffer  to  a  considerable  extent.  It  is  damaged, 
not  only  by  the  cocci  as  they  penetrate  into  it,  but  also  by  the  leucocytes  as 
they  pass  into  the  interstices  from  within  outwards.  The  injured  epithelium 
undergoes  mucous  degeneration,  peels  off  in  flakes,  and  disappears  in  places, 
leaving  a  denuded  mucous  surface. 

Soon  after,  the  inflammation  leads  to  the  mucosa  being  occupied  by  em- 
bryonic cells.  This  infiltration  is  limited  in  some  cases  to  the  superficial 
layers  only;  in  others  it  involves  the  mucosa  in  its  entire  thickness.  This 
latter  structure  is  then  roughened,  thickened,  and  inelastic,  and  bleeds 
readily.  Or,  again,  the  inflammation  may  extend  still  farther;  the  sub- 
epithelial connective  tissue  is  infiltrated  with  embryonic  cells,  and  this 
process  may  spread  to  the  corpora  cavernosa  and  affect  their  trabeculsB. 
The  network  of  the  corpora  cavernosa  begins  to  swell  and  to  undergo  infiltra- 
tion; phlebitis  supervenes,  and  there  is  also  some  endo-  and  peri-arteritis. 
The  dilated  capillaries  are  full  of  polymorphonuclear  leucocytes.  The  lym- 
phatics may  also  be  implicated ;  the  lymphatic  glands  become  enlarged  and 
painful,  and  may  even  suppurate. 

The  urethral  glands  (Morgagni's  lacunae  and  Littre's  glands)  have  their 
share  in  the  inflammatory  process,  and  this  is  of  the  utmost  importance, 
owing  to  the  role  which  inflammation  of  these  structures .  plays  in  chronic 
gonorrhea.  The  gonococci  are  present  around  the  glands.  They  are  not 
actually  on  the  epithelium  which  lines  the  glandular  lacunae,  but  they  are 
within  the  leucocytes  which  cover  it.  They  remain  between  the  cells  which 
line  the  excretory  ducts  of  Littre's  glands,  the  acini  of  which  contain  but 
leucocytes.  The  inner  surfaces  of  the  gland  ducts  undergo  partial  desquama- 
tion, and  are  then  invaded  by  leucocytes.  Finally  they  become  the  seat 
of  an  abundant  cell  proliferation ;  the  duct  walls  thus  become  thickened  and 
infiltrated  with  embryonic  cells.  Around  the  glands  this  process  spreads 
and  may  reach  the  corpora  cavernosa. 

The  infection  of  the  urethral  glands  terminates  either  by  sclerosis,  or  by 
the  obliteration  of  the  ducts,  or  by  their  transformation  into  cysts. 

We  have  so  far  only  considered,  from  the  pathological  point  of  view, 
the  infection  inasmuch  as  it  is  a  downward  spreading  process.  We  will  now 
turn  our  attention  to  its  extension  on  the  surface. 


THE  PATHOLOGY  OF  GONORRHEA 


69 


From  the  fossa  navicularis,  where  it  begins,  the  gonorrheal  inflammation 
spreads  backwards  to  a  variable  extent,  according  to  the  virulence  of  the 
infection,  the  constitution  of  the  patient,  and  the  treatment  applied,  which 
is  of  the  greatest  importance  in  this  respect. 

If  the  infection  stops  in  front  of  the  membranous  sphincter,  we  speak 
of  an  anterior  urethritis  ;  if  it  passes  beyond  that  muscle,  a  posterior  urethritis 
is  present.  The  involvement  of  the  posterior  urethra  occurs  in  60  or  70  per 
cent,  of  all  cases  (Finger,  Jadassohn).  A  posterior  urethritis  is  always  more 
serious,  owing  to  the  possibility  of  complications  arising,  such  as  prostatitis, 
vesiculitis,  cowperitis,  pyelonephritis,  etc. 


The  Pathology  of  Chronic  Urethritis. 

After  a  few  weeks  (usually  about  the  third),  the  acute  stage  of  gonorrhea 
has  passed  its  climax.     The  number  of  gonococci  diminishes;  the  phago- 


FiG.  23. 


cytosis  is  less  active ;  the  embryonic  infiltrations  are  resorbed ;  the  vascular 
changes  become  less  evident,  and  the  destroyed  epithelium  is  gradually 


Fig.  24. — Superficial  Infiltbation  of  the  Urethea  :  Proliferated 
Cylindrical  Epithelium.     (Motz.) 


regenerated.     The  process  of  repair  begins.     It  becomes  effectual  about  the 
fifth  or  sixth  week  by  the  formation  of  a  pavement  epithelium  composed 


70 


GONORRHEA 


of  several  strata.     In  no  instance  do  the  epithelial  cells  reassume  the  char- 
acter of  a  cylindrical  epithelium. 

When  this  proliferation  of  embryonic  tissue  is  too  active,  the  foundation 
for  future  stenoses  and  strictures  of  the  urethra  is  laid. 


Fig.  25. — Superficial  Infiltration  of  the  Urethra  :   Stratified  Cylindrical 
Epithelium,  covered  by  a  Layer  of  Pavement  Epithelium.    (Motz.) 

This  replacement  of  the  cylindrical  epithelial  cells  by  pavement  epi- 
thelium is  the  rule  in  gonorrhea.  The  epithelium  thus  becomes  finally  a  kind 
of  tough  skin  which  is  less  permeable  to  antiseptics  than  the  normal  one, 
and  has  lost  its  suppleness. 

A  restitutio  ad  integrum  is  thus  impossible,  and  all  cases  of  chronic  gonor- 
rhea which  are  neglected  invariably  develop  strictures. 

Lastly,  the  gonococci  which  were  present  in  the  depth  of  the  tissues 
and  in  the  caverns  of  the  glands,  disappear  about  the  sixth  week.  This  for- 
tunate issue  is,  however,  by  no  means  the  rule ;  usually  all  the  organisms  do 


Fig.  26. — Superficial  Infiltration  of  the  Urethra  :  Epithelial  Lining  composed 
OF  Many  Layers  of  Pavement  and  of  Cylindrical  Epithelium.     (Motz.) 

not  disappear.  A  number  of  them  remain  somewhere  in  the  tissues  or  in 
the  glands,  and  keep  up  the  inflammation  of  the  mucous  membrane.  The 
urethritis  then  becomes  chronic. 

Changes  in  the  Urethral  Epithelium. — In  chronic  urethritis,  the  first 
effect  of  the  inflammation  on  the  epithelium  is  the  stratification  of  the 
cylindrical  epithelium,  which  may  show  as  many  as  seven  or  eight  layers. 


THE  PATHOLOGY  OF  GONORRHEA 


71 


The  second  stage  is  the  evolution  of  the  epithelium  towards  keratiniza- 
tion.  The  urethra  is  covered  with  a  great  number  of  epithelial  layers, 
partly  of  the  cylindrical  and  partly  of  the  pavement  type.     Gradually  this 


Fig.  27. — Superficial  Infiltration  of  the  Urethra.    The  Epithelium  is 

KERATINIZED.       (Motz.) 

condition  changes,  until  a  number  of  flat,  keratinized  epithelial  strata  are 
formed  which  have  the  greatest  analogy  with  those  of  the  skin.  The  mucosa 
thus  loses  its  permeability  to  a  very  great  extent;  drugs  applied  to  it  for  a 
short  time  cannot  reach  its  deeper  layers,  and  therefore  remain  ineffective. 


l  "^  ■ .'  *  vsS'5  ■--<;>-  -■    .t'„i 


Fig.  28. — Chronic  Urethritis,  Epithelium  almost  Normal  :  Superficial  and 
Deep  Infiltrations;  Urethral  Adenitis.^     (Motz.) 

The  result  of  this  pathological  process  is  "  that  most  chronic  infiltrations 
are  protected  by  a  thick  shell  which  is  almost  impermeable  to  chemicals. 
This  is  the  true  reason  why  it  is  so  difficult  to  disinfect  these  superficial 

1  "  Adenitis  "  means  here,  and  in  the  following  figures,  "  inflammation  of  the  glands 
of  the  urethra  "  (A.  F.). 


72 


GONOEKHEA 


infiltrations,  whicli  sometimes  last  twenty  or  thirty  years,  as  the  autopsies 
on  patients  who  died  from  stricture  show."  ^ 

The  chorion  also  takes  part  in  the  inflammation,  and  is  infiltrated 
with  leucocytes  and  embryonic  cells.  These  embryonic  elements  form 
fibrous  tissue  which  ultimately  assumes  the  character  of  a  true 
cicatrix. 

The  lacunsB  of  Morgagni  also  participate.  They  begin  to  swell,  and  their 
orifices  take  the  shape  of  crater-like  elevations.    At  a  later  stage,  sclerosis 


Fig.  29. — Chkonic  Ukethritis  :  Stbatified  CyIiINDRIcal  Epithelium;  Super- 
ficial Embryonic  Ikpiltrations;  Adenitis.    (Motz.) 


supervenes:  in  some  cases  the  lacunae  retract,  atrophy,  and  disappear;  in 
others  their  orifice  becomes  obstructed,  and  they  become  filled  with  cellular 
debris,  and  are  converted  into  cysts  which  appear  on  the  surface  of  the 
mucous  membrane  as  whitish  nodules.  Less  often  they  suppurate,  and  give 
rise  to  peri-urethral  abscesses  and  fistulse. 

It  is  around  the  glands  of  Littre  that  the  infiltrative  lesions  are  most 
marked.  Several  forms  are  met  with :  either  the  glandular  secretion  increases, 
and  the  glands  become  swollen;  or  little  cysts,  filled  with  a  colloid  material, 
are  formed;  or  the  cell  proliferation  loosens  the  cylindrical  epithelium, 
destroys  the  sinus,  and  fills  the  gland  with  epithelial  debris;  or,  lastly,  the 

1  Motz,  Annul,  des  Malad.  des  Organes  Genito-Urin.,  1903,  p  419. 


THE  PATHOLOGY  OF  GONORRHEA 


73 


surrounding  fibrosis  strangulates  the  glands,  as  it  becomes  harder,  and 
contracts,  and  thus  causes  them  to  disappear  gradually. 
Thus,  Littre's  glands  are  liable  to  three  difierent  changes : 
1.  The  periglandular  infiltrations  lead  to  a  modification  in  the  epithelium 
which  lines  the  duct  of  the  gland.  This  epithelial  degeneration  is  similar 
to  the  one  on  the  surface  of  the  mucosa,  and  is  characterized  by  cell  prolifera- 
tion and  the  formation  of  pavement  epithelium.  The  gland  thus  ceases  to 
secrete,  and  its  acini  are  soon  filled  with  epithelial  neo -formations. 


Fig.  30. — Chronic  Glandular  Urethritis  :  Stratified  Cylindrical  Epithelium 
covered  by  several  layers  of  pavement  epithelium;  mucosa  and  sub- 

MUCOSA   CURED;   ADENITIS.      (Motz.) 


2.  The  periglandular  infiltration  retracts,  and  thus  gradually  compresses 
the  acini.  In  this  case  the  alteration  of  the  glandular  epithelium  is  purely 
passive;  it  undergoes  slowly  complete  destruction,  strangulated  by  the 
contracting  fibrous  tissue  around  it. 

3.  The  glands  are  shut  ofi  from  the  lumen  of  the  urethra,  and  are  con- 
verted into  cysts.  If  these  cysts  become  the  seat  of  an  acute  inflammation, 
they  tend  to  suppurate  and  to  give  rise  to  follicular  abscesses. 

The  urethral  glands  thus  play  an  important  role  in  gonorrheal  inflamma- 
tion; they  are  largely  responsible  for  the  deplorable  tenacity  of  certain 
urethrites.  In  the  glandular  culs-de-sac  the  gonococcus  finds  shelter,  even 
when  the  surface  of  the  mucosa  in  general  has  become  normal  again,  and  thus 
it  gives  rise  to  repeated  recrudescences  of  the  illness.  Under  the  influence  of 
the  same  factors  which  produce  congestion,  either  generally  or  locally,  the 


74 


GONOREHEA 


glandular  secretion  increases  suddenly,  and  carries  the  cocci  again  to  the 
surface  of  the  mucosa. 

The  peri-urethral  erectile  tissue  and  the  corpora  cavernosa  may  be 
invaded  by  the  same  changes  as  the  mucous  membrane.  The  inflammatory 
process  takes  a  similar  course.  At  first  numerous  round  cells  invade  the 
corpora  cavernosa;  then  connective-tissue  fibres  appear;  and  finally  hard 
retracted  bands  are  formed,  which  are  often  the  beginning  of  a  stricture. 

In  the  above  pages  the  primary  and  secondary  changes  which  are  found 
in  the  anterior  urethra  have  been  described.  A  few  further  remarks  on  the 
posterior  urethra  may  be  useful. 

The  two  common  phases  of  inflammation  are  also  met  with  in  the  posterior 
urethra.     They  take  a  similar  course :  at  first  there  is  cell  proliferation,  and 


Fig.  31. — Chronic  Superficial  and  Deep  Urethritis:  Keratinized  Epithelium; 
Superficial  Embryonic  Infiltrations;  Urethral  Adenitis.     (Motz.) 

especially  desquamation  of  the  cylindrical  epithelium;  then  regeneration 
takes  place,  and  conversion  of  the  cylindrical  epithelium  into  pavement 
epithelium. 

The  anatomical  conditions,  however,  modify  this  process  to  a  certain 
extent.  In  the  membranous  urethra  the  sphincter  causes  the  mucosa  to 
fissure  owing  to  its  energetic  contractions.  Thus,  more  or  less  deep  rhagades, 
which  present  a  red  base  and  bleed  easily,  are  formed  in  many  cases.  These 
ulcerations  heal  by  cicatrization,  and  tend  to  narrow  the  lumen;  hence  the 
great  frequency  of  strictures  in  this  region. 

In  the  prostatic  region  the  infiltration  distorts  the  mucous  membrane. 
The  fibrous  tissue  formed  compresses,  and  finally  obliterates,  the  orifices  of 


THE  PATHOLOGY  OF  GONORRHEA 


75 


the  ejaculatory  ducts.  The  latter  are  also  often  infiltrated,  and  their  walls 
become  rigid  and  gape. 

The  prostatic  glandules  become  the  seat  of  a  muco-purulent  or  purulent 
catarrh,  or  even  undergo,  as  a  result  of  periglandular  infiltration,  necrosis 
and  destruction.^ 

The  inflammatory  process  may  not  extend  beyond  the  superficial  layers 
of  the  subepithelial  tissue,  but  it  is  more  common  for  the  inflammation  to 
reach  the  deeper  structures,  and  this  extension  of  the  inflammation  takes 
place  chiefly  along  the  glands  and  their  excretory  ducts. 

Sometimes,  only  the  orifice  of  an  ejaculatory  duct  is  involved.  In  cases 
of  this  kind  the  opening  becomes  sclerosed  and  narrowed ;  hence  the  shooting 
pain  felt  by  certain  patients  during  ejaculation,  when  the  sperma  is  on  the 


Fig.  32. — Deep  Chronic  Urethritis  :  Keratinized  Epithelium;  Sclerosis  of 
Mucosa  and  Submucosa;  Deep  Infiltrations;  Adenitis.     (Motz.) 


point  of  passing  the  narrowed  orifice  of  the  duct.  Moreover,  these  rigid 
ejaculatory  ducts  close  the  seminal  vesicles  incompletely,  and  thus  sperma- 
torrhea is  not  infrequent  in  chronic  urethritis. 

The  epithelium  of  the  prostatic  glands  also  undergoes  changes,  of  which 
two  types  may  be  distinguished : 

Either  the  glands  are  filled  with  atrophied  and  desquamated  epithelium, 
in  which  case  the  prostatic  secretion  is  copious,  white,  opaque,  and  contains 
an  excessive  amount  of  epithelial  elements ;  or  they  are  filled  with  polymor- 
phonuclear leucocytes,  and  secrete  freely  a  thick  yellowish  mass — pus 
indicative  of  prostatitis. 

^  De  Keersmaecker  and  Verhoogen,  UUretrite.  Chronique  d'Origine  Gonococcique, 
Bruxelles  (Lamertin),  1898. 


76  GONORRHEA 

Urethral  Polypi. 

Gonorrhea  lias  an  incontestable  influence  on  tlie  formation  of  polypi  in 
the  nrethra.  Polypi  may  develop  as  an  immediate  result  of  the  inflamma- 
tion which  leads  to  hypertrophy  of  the  papillse ;  or  they  may  arise  at  a  later 
period  subsequently  to  the  formation  of  strictures.  Oberlander,^  Gregoire,^ 
and  Burckhardt,^  have  devoted  special  studies  to  them,  and  Dr.  A.  Pelletier 
has  published  a  very  interesting  paper^  on  this  subject. 


Fig.  33. — Polypi  of  the  Neck  of  the  Bladder  in  a  Woman  (Typical  Case 

DRAWN   FROM  NaTTJEE). 

According  to  Burckhardt,  four  varieties  of  polypi  are  found : 
1.  Caruncles. — These  are  small  vascular  tumours  with  a  more  or  less 
well-defined  pedicle,  which  are  chiefly  found  in  women.     They  resemble  a 
raspberry  in  aspect,  and  are  most  common  about  the  meatus.     Owing  to 

1  Oberlander,  "  Ueber  die  papillomatose  Schleimhautentziindung  der  inannlichen 
Harnrohre,"  Viertdjah.  f.  Dermat.  und  Syph.,  1887;  Lehrbuch  der  Urethroscopie,  1893. 

2  Gregoire,  "  Les  Polypes  de  I'Uretre  chez  la  Femme."     Ann.  des  Mai.  des  Org. 
Genito-Urin.,  1904,  p.  321. 

3  Burckhardt,  "  Die  Verletzungen  und  Chirurgischen  Erkrankungen  der  Harnrohre," 
Handbuch  der  Urologie,  1906,  vol.  iii.,  p.  267  (Die  Neubildungen  der  Harnrohre). 

^  Albert  Pelletier,  "  Les  Polypes  de  I'Uretre,"  La  Clinique,  1911,  p.  260. 


THE  PATHOLOGY  OF  GONORRHEA  77 

their  great  vascularity,  they  bleed  readily.  Histologically,  these  tumours 
are  composed  mainly  of  numerous  dilated  bloodvessels  covered  by  a  pave- 
ment epithelium  of  moderate  thickness. 

2.  Papillomata. — They  can  be  distinguished  with  the  naked  eye  owing 
to  the  presence  of  papillae.  Microscopically,  they  are  formed  by  a  thick 
layer  of  pavement  epithelium;  their  long  axis  is  occupied  by  bloodvessels. 

3.  Condylomata. — These  tumours  have  the  naked-eye  appearance  of 
little  cock's  combs.  Microscopically,  they  have  a  very  thick  epithelial 
lining  which  is  supported  by  a  compact  stroma  which  is  comparatively  poor 
in  cells  and  bloodvessels. 

4.  Glandular  and  Mucous  Polypi. — These  growths  owe  their  origin  to  a 
hypertrophy  of  the  glandular  culs-de-sac  of  the  mucous  membrane.  Their 
stroma,  which  is  covered  by  several  layers  of  epithelial  cells,  is  composed  of 
loose  tissue,  and  contains  numerous  glands. 

I  have  seen  a  polypus  of  this  type  in  a  doctor  who  consulted  me  in  1910. 
By  means  of  my  urethroscope  I  discovered  it  in  the  region  of  the  prostate, 
and  removed  it  with  a  pair  of  cutting  forceps.  The  histological  examination 
made  by  Dr.  Chenot  showed  it  to  be  an  "  adenoma  "  which  owed  its  origin, 
in  all  probability,  to  a  previous  attack  of  gonorrhea  which  had  set  up  a 
chronic  irritation  of  the  prostatic  cells. 


CHAPTER  VI 

THE  SYMPTOMATOLOGY  OF  ACUTE  GONORRHEA 

The  membranous  sphincter  of  the  urethra  is  a  well-defined  boundary  which 
the  gonococcus  usually  respects.  In  front  of  it,  we  have  the  anterior 
urethra  ;  behind  it,  is  the  posterior  urethra.  When  the  gonorrheal  infection 
reaches  this  latter  portion  of  the  urethra,  peculiar  and  special  symptoms 
appear  which  are  characteristic. 

Aeute  Anterior  Urethritis. 

Acute  anterior  urethritis  has  several  stages,  viz.  : 

1.  A  Period  of  Incubation. — In  most  cases  the  time  of  incubation  varies 
from  three  to  five  days.  Sometimes  it  is  shorter  (twenty -four  hours  or  less) ; 
in  other  instances  it  is  longer  (seven  to  eight  days).  An  incubation  period 
which  lasts  more  than  a  fortnight  is  quite  exceptional.  The  cases  in  which 
the  discharge  comes  on  at  so  late  a  date  are  usually  not  due  to  a  fresh 
infection;  they  are  sudden  exacerbations  of  a  gonococcal  infection  which 
has  been  present  for  a  considerable  time. 

2.  Prodromal  Symptoms. — One  observes  {a)  Local  Symptoms,  such  as 
redness  of  the  lips  of  the  meatus,  which  are  stuck  together.  Between  two 
micturitions  a  slightly  greyish  and  sticky  drop  is  formed,  which  on  micro- 
scopic examination  is  found  to  consist  of  epithelial  cells  of  the  pavement 
type,  a  few  leucocytes,  and  a  few  gonococci.  If  the  patient  makes  water 
into  several  glasses,  the  first  one  contains  turbid  urine,  laden  with  heavy 
flakes,  whilst  the  remainder  are  clear. 

(6)  Functional  Symptoms. — The  first  symptom  is  a  sensation  of  tingling 
and  slight  pricking,  which  comes  and  goes  suddenly,  "as  if  a  fly  were 
settling  down  "  (Diday). 

(c)  General  Symptoms. — They  are  characterized  by  a  certain  depression, 
fatigue,  and  loss  of  appetite. 

3.  Florid  Stage — (a)  Local  Symptoms. — The  inflammatory  phenomena 
appear  rapidly,  after  twenty-four  to  forty-eight  hours.  The  skin  of  the 
penis  and  the  prepuce  are  red  and  oedematous.^  The  latter  is  covered  with 
excoriations,  and  often  cannot  be  drawn  back  (inflammatory  phimosis). 

78 


THE  SYMPTOMATOLOGY  OF  ACUTE  GONORRHEA  79 

Under  the  skin  of  the  penis  the  inflamed  lymphatics  become  visible  as  cords 
running  along  the  dorsum.  The  glans  is  red,  inflamed,  and  covered  with 
small  ulcers,  which  sometimes  "  shine  like  a  ripe  cherry  "  (Hunter).  The 
lips  of  the  meatus,  which  reflect  the  condition  of  the  urethral  mucous 
membrane  "  in  the  same  way  as  the  tongue  is  the  mirror  of  the  alimentary 
canal "  (Diday),  are  red,  edematous,  and  often  excoriated.  There  is  a 
certain  degree  of  ectropion.  A  profuse  flow  of  pus  sets  in — a  regular 
"  incontinence  of  pus,"  as  Forgue  puts  it.  The  inflamed  urethra  is  like  a 
thick  rope  to  the  touch,  and  very  tender.  On  palpation  a  number  of  Httle 
nodules  of  the  size  of  millet-grains  are  felt  along  its  under-surf ace ;  they  are 
inflamed  glands  of  Littre.  The  discharge  becomes  thicker,  creamy,  yellow, 
and  purulent.  Towards  the  end  of  the  first  week  it  assumes  a  more  greenish 
tint,  and  produces  the  characteristic  spots  on  the  linen.  In  the  centre  of 
these  stains  is  a  thick  purulent  zone,  surrounded  by  a  lighter  halo  which 
corresponds  to  the  serous  constituent  of  the  discharge. 

The  flow  is  always  greatest  in  the  morning,  because  the  patient  micturates 
but  little,  if  at  all,  during  the  night.  In  the  daytime  the  urethra  is  frequently 
cleansed  by  making  water. 

The  reaction  of  the  discharge  is  alkaline. 

(&)  Functional  Symptoms. — At  this  stage  appears  the  characteristic 
symptom  of  pain.  Those  affected  with  gonorrhea  suffer  during  micturition, 
during  erection,  and  during  ejaculation.  The  pain  on  making  water  is 
more  or  less  pronounced;  occasionally  it  is  unbearable.  Some  patients  feel 
as  if  they  were  "  passing  a  red-hot  iron,"  or  as  if  they  had  "  razors  in  their 
pipe."  The  severity  of  the  pain  depends  to  a  large  extent  on  the  suddenness 
with  which  the  flow  of  urine  dilates  the  inflamed  passage.  In  most  cases 
the  pain  is  sharp,  shooting,  or  burning.  This  last-mentioned  character  has 
left  a  lasting  impression  on  the  French  mind;  hence  the  popular  term  of 
"  chaudepisse  "  for  gonorrhea.  The  patients  usually  dread  the  act  of 
micturition,  and  delay  it  as  much  as  possible,  and  eventually  they  proceed 
with  the  utmost  caution.  The  seat  of  the  pain  on  making  water  varies;  it 
is  usually  located  all  along  the  penile  portion ;  occasionally  it  is  the  perineum 
which  feels  "  heavy." 

Owing  to  the  swelling  of  the  mucous  membrane,  the  lumen  of  the  urethra 
is  narrowed,  and  thus  a  certain  mechanical  diflS.culty  in  making  water  is 
produced.  The  stream  is  smaller,  thin,  split,  and  sometimes  resembles  a 
spray.     In  the  very  acute  cases  the  patients  micturate  drop  by  drop. 

In  a  few  rare  instances  a  certain  degree  of  retention  is  present,  which  is 
partly  due  to  the  swelling  of  the  mucosa,  and  partly  to  spasm  of  the  mem- 
branous region.  At  this  stage  the  patient  is  constantly  troubled,  when  he 
lies  down,  by  erections  which  result  from  the  congestion  of  the  parts  in  the 
horizontal  position,  the  warmth  of  the  bed,  or  from  lascivious  dreams  or  his 


80  GONOERHEA 

compulsory  abstinence.  These  erections  are  usually  accompanied  by  sbarp 
pains,  because  the  mucous  membrane  loses  its  elasticity,  and  its  dilatability 
when  it  is  inflamed.  The  patient  tries  to  rid  himself  from  these  erections 
by  getting  up,  or  by  putting  cold  compresses  on  his  penis,  and  ultimately 
succeeds ;  but  as  soon  as  he  returns  to  his  bed,  he  is  in  as  bad  a  plight  as 
before.  When  these  erections  are  followed  by  pollutions  (so-called  "  wet- 
dreams  "),  the  ejaculations  give  rise  to  intense  pain;  they  may  even  lead 
to  slight  Assuring  of  the  mucosa.  In  this  way  the  slight  hemorrhages  occur 
which  one  meets  with.  They  often  cause  the  pus  and  the  sperma  to  be  blood- 
stained, a  condition  which  has  been  decorated  with  the  name  "  Russian  clap." 

As  the  elasticity  of  the  mucosa  is  diminished,  the  latter  cannot  follow 
the  expansion  of  the  corpora  cavernosa  during  erection,  and  thus  the  penis 
becomes  distorted.  In  slight  cases,  only  the  glans  is  bent,  but  in  severer 
cases  the  entire  penis  becomes  arched.  This  condition  is  known  as  chorda 
venerea,  or  chordee,  and  is  said  by  many  authorities  to  be  due  to  the  con- 
traction of  the  longitudinal  unstriped  muscle  fibres  of  the  urethral  sub- 
mucous tissues. 

The  pain  of  chordee  has  led  some  ignorant  patients  to  seek  relief  by 
placing  their  erect  distorted  penis  on  a  firm  flat  support,  and  attempting  to 
straighten  it  by  hammering  it  into  shape  with  their  fist.  This  deplorable 
practice  is  apt  to  be  followed  by  serious  accidents ;  the  urethra  ruptures  at 
some  point  or  other,  and  it  may  bleed  so  furiously  that  death  takes  place, 
as  in  the  case  recorded  by  Voillemier.  Moreover,  extravasation  of  urine, 
sepsis,  and  traumatic  stricture,  are  apt  to  supervene. 

(c)  General  Symptoms. — The  troubles  mentioned  are  accompanied  by 
general  systemic  disturbances,  such  as  slight  chills,  lassitude,  loss  of  appetite, 
fatigue,  and  an  earthy  pallor.  Slight  fever  up  to  38°  C.  (100-4°  P.)  is  also 
not  uncommon. 

The  gonococcus  produces  a  general  intoxication  of  the  body  which  is 
characterized  by  pallor,  loss  of  appetite,  wasting,  headache,  and  a  typical 
anemia.^ 

In  many  instances  these  systemic  troubles  are  insignificant,  and  a  good 
number  of  patients  "  drip  "  calmly  for  fifteen  to  thirty  days,  without  showing 
much  worry  or  anxiety. 

The  acute  stage  of  gonorrheal  inflammation  reaches  its  height  about  the 
middle  or  the  end  of  the  third  week,  after  which  improvement  sets  in,  if 
there  are  no  complications. 

4.  Period  of  Decline. — After  twelve  to  fourteen  days  the  symptoms 
become  less  marked.  The  inflammation  of  the  glans  and  of  the  meatus 
diminishes  progressively;  the  walls  of  the  urethra  become  supple  again,  and 
gradually  regain  their  normal  aspect.     Micturition  and  erection  cease  to  be 

1  Vide  Chapter  III.,  Gonococcal  Septicemia. 


THE  SYMPTOMATOLOGY  OF  ACUTE  GONORRHEA  81 

accompanied  by  pain.  The  microscopic  examination  shows  fewer  and 
fewer  gonococci  and  pns  cells,  whilst  more  and  more  epithelial  cells  are 
found,  especially  of  the  pavement  type.  The  urine  becomes  clearer,  and 
finally  only  the  first  glass  contains  a  few  filaments. 

The  usual  duration  of  an  acute  anterior  urethritis  is  about  five  to  six 
weeks.  Recurrences  are  frequent.  They  are  due  to  the  numerous  recesses 
in  the  mucosa  in  which  the  gonococci  lodge  themselves,  and  remain  latent 
for  a  considerable  time.  A  spontaneous  cure  is  very  rare.  As  a  rule 
inflammatory  areas  are  left  which  keep  up  a  chronic  urethritis.  The  course 
of  the  malady  is  largely  influenced  by  the  age  of  the  patient.  In  old  people 
there  is  a  marked  tendency  for  the  disease  to  spread  rapidly  to  the  bladder 
and  to  the  kidneys.  There  is  a  great  variety  of  different  clinical  types, 
but  they  are  not  sufficiently  definite  and  distinct  to  deserve  individual 
descriptions. 

The  phase  of  decline  is  of  variable  length.  It  may  last  two  or  three 
weeks,  but  it  has  no  definite  limit,  as  all  depends  on  the  observance  of  the 
necessary  hygienic  measures  and  on  the  treatment.  Carelessness  and  a 
misdirected  therapy  invariably  prolong  the  course  of  the  disease. 

Acute  Posterior  Urethritis. 

Inflammation  of  the  posterior  urethra  is  an  infinitely  more  formidable 
illness  than  anterior  urethritis,  owing  to  the  complications  which  may  arise^ 
such  as  cystitis,  epididymitis,  prostatitis,  and  vesiculitis.  These  troubles 
are  very  common,  and,  as  the  posterior  urethra  is  affected  in  almost  80  per 
cent,  of  all  cases,  an  early  diagnosis  of  this  inflammation  is  imperative. 

Etiology  of  Posterior  Urethritis. — Some  authors,  like  Heissler,^  have 
maintained  that  the  posterior  urethra  is  always  involved  during  an  attack 
of  gonorrhea.  This  view,  however,  appears  to  be  exaggerated,  and  there 
is  very  little  doubt  that  in  a  considerable  number  of  cases  the  anterior  urethra 
is  alone  affected. 

There  are  many  causes  for  the  spreading  backwards  of  the  gonorrheal 
infection  to  the  posterior  urethra.  In  some  cases  this  appears  to  occur 
spontaneously  without  any  therapeutic  interference.  But  there  is  practically 
always  a  definite  cause  for  the  invasion  of  the  posterior  urethra  by  the 
gonococcus,  and  one  can  find  it,  if  one  takes  the  trouble  to  look  for  it.  General 
or  local  fatigue,  such  as  excessive  drinking,  coitus,  prolonged  erections,  and 
violent  exercise  (long  walks,  cycling,  riding),  are  responsible  in  certain  cases ; 
in  others  the  fault  is  to  be  found  in  neglecting  to  keep  the  parts  clean. 

But  the  principal  cause  for  the  onset  of  a  posterior  urethritis  is  the 
practice  of  giving  injections  into  the  anterior  urethra  by  means  of  a  small 

1  Heissler,  Arch.  f.  Dermitolog.  und  Syphilis,  1891,  vol.  xxiii.,  p.  765. 


82  GONOEKHEA 

syringe.  This  dangerous  custom  should  be  given  up  for  good.  An  energetic 
patient  has  only  to  inject  a  certain  amount  of  fluid,  pushing  the  piston  as 
far  as  it  will  go,  and  to  keep  his  urethra  closed  at  the  same  time ;  the  walls  of 
the  canal  are  then  under  tension,  and  the  fluid  tends  to  seek  an  outlet. 
Finally  the  membranous  sphincter  yields,  and  the  liquid,  which  is  full  of 
gonococci,  enters  the  posterior  urethra,  and  infects  it  with  the  pus  from  the 
anterior  part. 

Another  important  cause  is  a  clumsily  and  hadly  given  urethro-vesical 
irrigation.  In  nearly  every  instance  the  first  irrigations  do  not  enter  the 
posterior  urethra  easily,  unless  the  patient  is  an  habitue.  The  membranous 
sphincter  contracts,  and  keeps  the  liquid  back.  The  gonococci  are  thus 
driven  into  the  posterior  limit  of  the  anterior  urethra,  and  settle  down  there, 
as  no  flow  of  antiseptic  fluid  removes  them  immediately. 

As  we  shall  see  later  on,  in  the  chapter  on  Treatment,  a  well-given 
urethro-vesical  irrigation  is  the  best  safeguard  against  the  onset  of  a  posterior 
urethritis.     It  is  just  as  beneficial  as  a  clumsy  irrigation  is  harmful. 

Another  common  cause  for  the  development  of  a  posterior  urethritis 
is  the  untimely  passing  of  a  catheter — for  instance,  if  it  is  carried  out  without 
urgent  need,  and  without  sufficient  previous  disinfection  of  the  anterior 
urethra. 

At  all  events,  it  is  absolutely  necessary  to  diagnose  a  posterior  urethritis 
at  the  earliest  possible  moment.  Under  immediate  and  proper  treatment 
this  trouble  tends  to  heal  rapidly,  and  without  any  further  damage ;  but  it 
is  prone  to  cause  a  number  of  serious  complications  if  neglected. 

A  patient  who  consents  to  stay  in  bed  from  the  beginning  of  his  gonorrhea 
on,  who  commits  no  carelessness  and  no  therapeutic  error,  has  the  greatest 
possible  chance,  if  not  the  certainty,  of  escaping  an  infection  of  his  posterior 
urethra. 

Symptoms  of  Acute  Posterior  Urethritis. — Posterior  urethritis  comes  on 
during  the  first  or  second  week  of  acute  gonorrhea.  Its  onset  is  insidious,  so 
much  so  that  most  patients  are  unaware  of  their  trouble ;  but  it  is  just  this 
benign  character  of  the  symptoms  which  should  attract  the  attention  of  the 
surgeon. 

The  cardinal  symptoms  of  this  condition  are  the  following : 

1.  The  Small  Amount  of  Discharge  visible  at  the  Meatus. — ^When  the 
posterior  urethra  becomes  infected  during  an  ordinary  attack  of  gonorrhea, 
one  frequently  finds  that  the  discharge  suddenly  diminishes  considerably  in 
a  day  or  so.  The  patient  is  usually  very  pleased  when  he  notices  this 
apparent  improvement.  One  should,  however,  not  share  his  joy,  and  keep 
a  careful  watch  over  his  posterior  urethra,  which  is  in  danger. 

2.  The  Turbidity  of  the  Urine. — All  four  glasses  are  turbid  if  the  patient 
makes  water  into  four  glasses.  This  sign  is  extremely  important,  for  it  is 
the  first  clue  to  the  diagnosis  of  a  posterior  infection  if  the  case  has  been 


THE  SYMPTOMATOLOGY  OF  ACUTE  GONOERHEA  83 

treated  with  permanganate  irrigations.  It  should  be  a  hard-and-fast  rule  to 
examine  the  urine  of  all  patients  who  are  treated  with  urethro-vesical 
irrigations  every  day  by  the  four-glass  method. 

3.  The  Frequency  of  Micturition. — This  functional  symptom  is  not  present 
in  the  beginning,  but  it  comes  on  soon.  Its  causation  is  not  so  much  the 
injfiammation  of  the  posterior  urethra  as  that  of  the  neck  of  the  bladder. 
There  is  vesical  tenesmus ;  the  micturitions  become  imperative  and  irresistible. 
The  patient  has  to  make  water  every  ten  or  five  minutes,  quite  irrespectively 
of  the  amount  of  urine  contained  in  the  bladder. 

4.  Pain. — The  pain  assumes  almost  at  once  the  character  of  the  pain 
observed  in  cystitis,  and  is  marked  by  its  intensity  at  the  end  of  micturition. 

Apart  from  these  four  cardinal  symptoms,  there  are  others  which  should 
not  escape  a  careful  observer's  notice.  "  Wet-dreams  "  become  frequent 
owing  to  the  implication  of  the  verumontanum  in  the  inflammation.  Slight 
terminal  hematuria  is  also  found  occasionally.  Lastly,  the  general  health 
is  impaired.  The  patient,  who  so  far  may  have  been  very  well  in  himself, 
feels  tried,  worn  out,  and  complains  of  loss  of  appetite.  His  eyes  are  hollow 
and  surrounded  by  dark  rings.  A  curious  and  characteristic  pallor  is  seldom 
wanting;  the  patient  is,  and  feels,  a  wreck. 

When  these  symptoms  are  present,  a  surgical  examination  becomes 
urgent;  the  prostate  should  be  examined  by  palpation  fer  rectum.  In  the 
early  moments  of  acute  posterior  urethritis  this  exploration  gives  but  little 
information  or  none ;  but  after  a  couple  of  days  it  is  nearly  always  possible 
to  make  out  a  painful,  doughy  spot  in  the  prostate,  or  a  general  enlargement 
of  the  organ.  The  prostate  is  thus  of  the  greatest  importance  in  the 
pathology  of  posterior  urethritis.  The  same  is  true  for  the  seminal  vesicles, 
which  should  always  be  examined,  and  any  change  in  them  should  be  noted. 

Chronic  Posterior  Urethritis. 

Symptoms. — The  symptoms  which  characterize  a  lesion  of  the  posterior 
urethra  in  chronic  urethritis  are  generally  not  well  known,  and  often  escape 
the  notice  of  the  patient,  as  they  are  usually  trifling,  and  as  the  discharge  is 
reduced  to  a  minimum,  a  slight  moisture.     The  chief  signs  are  the  following: 

1.  The  Filaments  in  the  Urine. — When  the  patient  makes  water  into  four 
glasses,  heavy  filaments  are  constantly  found,  chiefly  in  the  first  and  fourth 
glasses. 

2.  The  Pains. — The  pains  complained  of  by  the  patients  are  usually 
vague,  unpleasant  sensations  about  the  urogenital  region.  In  slight  cases 
complaint  is  made  of  an  indefinite  heavy  feeling  about  the  "  back  of  the 
pipe,"  or  the  patient  has  a  sensation  of  heat,  or  tickling,  or  of  the  presence 
of  a  weight,  or  foreign  body,  in  his  posterior  urethra.  On  other  occasions  the 
patients  claim  that  their  urethra  burns,  especially  when  they  make  water. 


84  GONOEEHEA 

These  different  sensations  are  mainly  present  at  tlie  moment  of,  or  at  the 
end  of,  micturition,  but  they  may  be  permanent.  Neuralgic  pains  shooting 
about  the  perineum,  the  groin,  and  the  testicles,  are  also  complained  of,  even 
when  there  is  not  the  slightest  evidence  of  epididymitis.  They  sometimes 
radiate  to  the  loins,  the  sacral  region,  the  upper  part  of  the  thigh,  or  the  whole 
pelvis,  and  worry  the  patient  when  he  is  sitting  down,  and  more  so  when  he 
walks,  or  rides  on  horseback. 

3.  Neurasthenic  Troubles. — ^Patients  who  have  lesions  in  their  posterior 
urethra  are  nearly  always  neurasthenics;  they  suffer  from  "  sexual  neuras- 
thenia." Pains  in  the  region  of  the  kidneys,  headache,  vertigo,  feelings  of 
anxiety  and  of  fainting  are  their  lot,  and  the  indefinite  character  of  their 
trouble  leads  them  to  go  from  one  doctor  to  another.  Very  often  the  true 
nature  of  their  illness  is  not  detected  for  a  long  time.  This  neurasthenia 
ultimately  culminates  in  sexual  impotence  ;  the  erections  are  incomplete,  and 
lead  to  nothing  satisfactory,  and  finally  the  patients  become  hypochondriacs 
on  a  sexual  basis. 

4.  Ejaculatory  Troubles. — There  are  four  different  varieties  which  one 
meets  with — ^namely : 

{a)  Loss  of  Semen  may  occur,  especially  when  the  patient  empties  his 
bowels,  or  there  is  spermatorrhea  or  prostatorrhea  at  the  end  of  micturition, 
or  frequent  "  wet-dreams,"  or  premature  ejaculations — ejaculatio  ante  fortas, 
as  somebody  has  termed  them — may  be  complained  of. 

(&)  Pain  during  Ejaculation. — In  some  cases  the  voluptuous  sensation 
during  coitus  is  lost;  in  others  an  intense  pain  is  felt  at  the  height  of  the 
orgasm.  Definite  pathological  conditions,  which  have  been  carefully  studied, 
underlie  these  symptoms.  There  is  atresia  of  the  orifices  of  the  ejaculatory 
ducts  in  these  cases.  The  ducts  have  lost  their  suppleness;  they  have 
become  rigid,  and  their  lumen  is  narrowed  by  the  formation  of  strictures. 
When  the  sperma  is  vigorously  sent  through  them  during  ejaculation,  they 
cannot  dilate  properly  under  the  pressure,  and  thus  give  rise  to  pain. 

(c)  Bloodstained  Ejaculations. — Chronic  lesions  in  the  posterior  urethra 
are  always  to  be  expected  when  a  patient  complains  that  his  sperma  is  blood- 
stained. The  latter  may  be  definitely  red,  in  which  case  a  simultaneous 
inflammation  of  the  seminal  vesicles  is  probable,  or  it  may  be  simply  streaked 
with  blood,  in  which  case  lesions  of  the  verumontanum  are  likely  to  be 
present. 

Xiastly,  retrograde  ejaculations  are  sometimes  noted.  Instead  of  being 
expelled  in  the  normal  way  outside  the  body,  the  sperma  runs  backwards 
into  the  bladder,  which  it  leaves  subsequently  mixed  with  urine. 

{d)  Repeated  Attacks  of  Epididymitis. — This  is  another  equally  character- 
istic symptom  of  chronic  posterior  urethritis.  Sometimes  the  epididymitis 
recurs  at  variable  intervals  in  the  same  testis ;  in  other  instances  both  sides 
are  affected  alternately,  a  condition  known  as  orchite  a  bascule. 


CHAPTER  VII 

THE  DIAGNOSIS  OF  URETHRITIS 

The  diagnosis  of  urethral  inflammation  is  of  the  utmost  importance.  On 
its  correctness  and  completeness  depends  the  choice  of  treatment,  and 
one  may  say  without  exaggeration  that  a  rational  and  well-planned  therapy 
invariably  leads  to  a  certain  and  permanent  cure.  The  surgeon  should 
therefore  direct  all  his  efforts  towards  a  good  diagnosis,  and  for  this  purpose 
he  should  keep  all  the  principal  symptoms  which  we  are -about  to  describe 
carefully  in  mind.     He  should  consider — 

1.  The  urethral  secretions. 

2.  The  walls  of  the  urethra  proper. 

3.  The  glands  connected  with  the  urethra. 

1.  Examination  of  the  Urethral  Secretions. 

It  is  a  mistake  to  confine  oneself  to  the  examination  of  the  purulent 
discharge  which  appears  at  the  meatus.  It  is  essential  to  investigate  also 
the  secretions  which  remain  in  the  canal  for  a  certain  time,  and  are  only 
expelled  during  micturition — namely,  the  filaments. 

One  has  therefore  to  examine — 

1.  The  urethral  discharge  proper. 

2.  The  filaments  found  in  the  urine. 

1.  Examination  of  the  Discharge. — First  of  all  one  has  to  satisfy  oneself 
that  the  discharge  complained  of  really  comes  from  the  urethra,  and  not 
from  a  neglected  or  unsuspected  balanoposthitis.  Individuals  who  suffer 
from  phimosis,  very  often  develop  under  their  long  and  tight  foreskin, 
which  permanently  covers  their  glans,  an  ulcer,  or  a  chancre,  or  warts. 
These  conditions  are  apt  to  give  rise  to  a  discharge,  which  could  easily  be 
diagnosed  wrongly,  and  be  mistaken  for  a  discharge  from  the  urethra.^ 

Then  there  are  patients  who  are  addicted  to  the  practice  of  injecting 
antiseptic  solutions  into  their  urethra  in  order  to  cure  the  gonorrhea  which 
they  believe  themselves  to  be  suffering  from.     All  they  achieve  is  to  set  up 

85 


86  GONORKHEA 

a  chemical  urethritis  which  could  easily  have  been  avoided  had  a  properly 
conducted  medical  examination  been  made. 

As  to  the  discharge  itself,  one  has  to  ascertain,  in  the  first  place,  if  it  is 
continuous,  and  if  it  shows  itself  again  within  an  hour  or  an  haK-hour 
after  having  made  water — a  characteristic  feature  of  a  still  evolving  attack 
of  acute  gonorrhea — or,  if  there  is  but  a  drop,  rather  pointing  to  an  inflam- 
mation of  a  chronic  nature.  Then,  again,  one  has  to  consider  if  the  discharge 
is  present  during  the  day  or  only  in  the  morning,  in  which  latter  case  one 
has  to  deal  with  a  true  "  gleet."  Is  the  discharge  so  scanty  that  it  only  just 
forms  a  little  scab  or  crust  over  the  lips  of  the  meatus,  causing  it  to  be 
sticky  ? 

The  colour  of  the  discharge  should  also  be  noted.  It  may  be  white,  or 
yellow,  or  green,  or  greyish,  or  opalescent,  or  clear  like  glycerine.  Every  one 
of  these  tints  bears  a  definite  relation  to  the  amount  of  pus  cells  contained 
in  the  discharge. 

Its  consistence  is  also  of  importance.  Is  it  uniform,  "  laudable,"  pus, 
or  is  it  flaky  ?  Is  it  viscous  and  slimy,  and  does  it  stain  the  linen  ?  Not 
infrequently  the  discharge  is  represented  solely  by  a  drop  of  clear  fluid,  like 
water,  and  is  only  visible  in  the  morning.  During  the  day  the  lips  of  the 
meatus  are  only  slightly  stuck  together.  This  condition  corresponds  to 
Diday's  "  mucous  oozing,"  or  urorrhea.  A  discharge  of  this  kind  contains 
but  very  few  epithelial  elements ;  occasionally,  also,  a  small  number  of  odd 
bacteria  are  found,  but  never  any  pus  cells. 

2.  Examination  of  the  Filaments  in  the  Urine. — A  painstaking  examina- 
tion of  the  filaments  found  in  the  urine,  and  their  differentiation,  are  of  the 
greatest  importance,  and  should  never  be  omitted.  By  examining  the 
filaments  methodically,  an  experienced  eye  can  at  once  establish  the  basis  of 
his  diagnosis. 

One  is  thus  also  enabled  to  control  the  result  of  a  methodical  treatment, 
and  to  tell  approximately — although  not  with  certainty — ^whether  the 
patient  is  cured  or  not.  To  satisfy  oneself  that  the  patient's  meatus  is  no 
longer  sticky,  and  that  he  has  no  sign  of  a  discharge,  is  not  sufficient  for 
giving  him  a  clean  bill  of  health.  It  is,  amongst  other  further  precautions, 
absolutely  essential  to  ascertain  that  there  are  no  filaments  in  the  urine. 
To  act  diflerently  means  running  the  risk  of  serious  miscalculations,  of  which 
the  least  dangerous  one  would  be  to  see  the  patient  return  a  few  days  after 
his  supposed  cure,  with  a  recurrence  of  his  discharge,  or  with  an  epididymo- 
orchitis,  or  with  some  other  complication. 

It  is  best  to  examine  the  first  urine  which  the  patient  passes  in  the 
morning ;  but  in  practice  this  cannot  always  be  carried  out,  and  it  is  sufficient 
in  most  cases  to  test  a  specimen  which  is  obtained  three  to  four  hours  after 
the  last  micturition. 


THE  DIAGNOSIS  OF  UEETHRITIS  87 

If  the  urine  is  turbid,  it  is  one's  first  duty  to  ascertain  tliat  this  turbidity 
is  not  due  to  the  precipitation  of  salts,  chiefly  phosphates,  in  an  alkahne 
urine.  For  this  purpose  a  few  drops  of  acetic  acid  are  poured  into  the 
turbid  urine ;  if  phosphates  be  present,  they  are  immediately  dissolved,  and 
the  urine  becomes  clear.  The  omission  of  this  test  is  apt  to  lead  to  serious 
mistakes. 

In  order  to  differentiate  the  various  filaments  found  in  the  urine  according 
to  their  origin,  a  number  of  methods  have  been  devised,  which  we  will  rapidly 
review  here. 

Thompson's  Method. — Thompson's  method  is  very  simple,  but  also  very 
inaccurate.  It  consists  in  making  the  patient  pass  his  water  into  two  glasses 
only. 

The  first  glass  is  supposed  to  represent  the  condition  of  the  anterior 
urethra,  and  the  second  one  that  of  the  posterior  urethra. 

If  we  exclude  all  patients  who  suffer  from  renal  or  vesical  lesions  which 
give  rise  to  turbid  urine  and  to  special  symptoms,  and  only  consider  cases 
of  urethritis,  then  three  groups  of  cases  can  be  distinguished : 

1.  Both  glasses  are  turbid. 

2.  The  first  one  is  turbid,  the  second  one  clear. 

3.  Both  glasses  are  clear ;  but  there  are  filaments, 

in  one  or  in  both. 

Each  of  these  different  groups  has  a  different  signification. 

The  first  two  (turbid  urine)  indicate  diffuse  acute  or  recent  superficial 
lesions.  In  the  first  instance  the  urethritis  is  a  total  one ;  in  the  second 
group  the  anterior  urethra  is  alone  affected. 

The  third  alternative  is  the  most  common  (clear  urine  with  filaments), 
and  means  practically  always  a  localized  chronic  lesion. 

But  to  distinguish  between  lesions  of  the  anterior  and  of  the  posterior 
urethra  in  this  case  is  extremely  diflS.cult. 

Thompson's  two-glass  method  is  based  on  the  purely  theoretical  assump- 
tion that  the  external  sphincter  of  the  bladder  divides  the  urethra  anatomic- 
ally, and  physiologically  into  two  distinct  portions.  This  muscle  is  supposed 
to  form  so  impassable  a  barrier  that  all  secretions  which  are  formed  in  the 
anterior  urethra  are  at  once  driven  towards  the  meatus,  whilst  those  of  the 
posterior  portion  flow  back  into  the  bladder  and  mix  with  the  urine.  This 
view  is  more  theoretical  than  practical,  for  common  experience  tells  that, 
in  the  overwhelming  majority  of  cases,  the  filaments  are  found  in  the  first 
glass  whether  they  come  from  the  anterior  or  from  the  posterior  urethra. 
The  first  stream  of  urine  drives  them  out  of  the  meatus,  and  thus  they  fall 
into  the  first  glass,  so  much  so  that  there  is  no  need  for  the  second  glass  to 
contain  any  filaments  at  all. 


88  GONOEEHEA 

Thompson's  metliod  is  thus  quite  useless  for  accurate  work. 

Supposing  the  patient  passes  very  little  urine  into  the  first  glass,  less  than 
necessary  for  washing  away  all  the  filaments,  the  latter  are  then  found  in 
the  second  glass,  even  if  they  originated  in  the  anterior  urethra. 

Again,  in  cases  of  obvious  posterior  urethritis,  pus  and  debris  may  be 
present  in  the  first  glass,  whilst  the  second  one  is  quite  clear,  owing  to  the 
fact  that  the  first  lot  of  urine  sufficed  to  cleanse  the  urethra  completely. 
In  cases  of  this  kind  a  wrong  diagnosis  would  be  made  with  certainty  were 
one  to  rely  upon  this  method. 

However,  one  must  admit  that  a  posterior  urethritis  is  usually  present 
when  big  and  heavy  filaments  are  found  in  the  second  glass.  A  control  by 
other  methods  of  investigation  is,  however,  always  required  (cross-examina- 
tion of  the  patient  in  order  to  ascertain  if  he  has  suffered  from  cystitis  or  epi- 
didymitis, and,  still  more  important,  examination  of  the  prostate  "per  rectum). 

Kollmann's  Method. — Professor  Kollmann  of  Leipzig  has  devised  a 
five-glass  method  which  safeguards  against  the  errors  of  Thompson's  process. 

The  examination  is  best  carried  out  in  the  early  morning,  before  the 
patient  has  made  his  first  water.  His  anterior  urethra  is  washed  out  with 
a  syringe,  or  through  a  soft  sound  passed  as  far  as  the  bulb,  the  patient 
standing  upright,  and  great  care  being  taken  to  irrigate  slowly,  and  not  to 
force  the  sphincter.  The  washings  are  all  collected  in  th^  first  glass  as  long 
as  filaments  come  away.  When  the  irrigation  fluid  is  returned  quite  clear, 
a  result  which  is  only  obt^ained  after  |  to  1  litre  has  been  used,  it  is  collected 
in  the  second  glass,  which  is  kept  as  evidence  that  the  anterior  urethra  has 
been  thoroughly  washed.  The  patient  then  makes  water  into  the  other 
three  glasses.  If  one  of  them  contains  filaments,  or  if  the  urine  is  turbid, 
the  phosphates  having  been  eliminated,  then  the  posterior  urethra  must  be 
aflected.  If,  on  the  other  hand,  neither  turbidity  nor  filaments  are  present, 
whilst  the  fkst  glass  (containing  the  washings)  is  full  of  filaments,  the 
anterior  urethra  is  alone  diseased. 

Kollmann's  five-glass  method  is  absolutely  accurate  when  applied  with 
care. 

Young  of  Baltimore  has  developed  this  method  into  a  seven-glass 
process.  He  first  washes  the  anterior  urethra:  first  glass.  The  patient 
compresses  his  urethra  at  the  root  of  the  penis,  and  the  washings  are  con- 
tinued until  they  are  returned  perfectly  clear :  second  glass.  A  glass  tube  is 
now  inserted  as  far  as  the  bulb,  and  one  irrigates  again  until  no  more  fila- 
ments come  away ;  these  washings  are  the  third  and  fourth  glasses.  The 
patient  then  empties  his  bladder  into  the  fifth,  sixth,  and  seventh  glasses. 

The  Jadassohn-Goldberg  Method.' — The  anterior  urethra  is  washed  care- 
fully with  a  syringe  until  the  washings  return  quite  clear.  These  washings 
contain,  of  course,  the  secretions  of  the  anterior  urethra  only. 


THE  DIAGNOSIS  OF  URETHRITIS  89 

The  patient  then  makes  water  into  two  glasses,  and  any  pus  or  purulent 
debris  found  in  them  necessarily  comes  from  the  posterior  urethra. 

This  method  allows  one  to  distinguish  clearly  between  the  secretions  of 
the  anterior  urethra  and  those  of  the  posterior  urethra ;  but  it  does  not  allow 
one  to  differentiate  between  those  of  the  posterior  urethra  and  those  of  the 
bladder.  The  same  criticism  applies  to  Krohmeyer's  method,  which  we 
will  consider  next. 

Krohmeyer's  Method. — Krohmeyer  injects  or  instils  4  or  5  c.c.  of  a 
O'l  per  cent,  solution  of  methylene-blue  into  the  anterior  urethra,  and  allows 
this  fluid  to  be  retained  for  a  few  minutes.  The  patient  then  makes  water 
into  several  glasses.  Any  filaments  stained  blue  are  derived  from  the 
anterior  urethra,  whilst  those  of  the  posterior  urethra  are  colourless. 

Lohnstein's  method  is  very  similar. 

Lohnstein's  Method. — Before  the  first  lot  of  urine  has  been  passed  in  the 
morning,  a  0-5  per  cent,  solution  of  potassium  ferrocyanide  is  injected  into 
the  anterior  urethra  until  the  fluid  comes  out  clear.  Great  care  must  be 
taken  not  to  force  the  sphincter. 

All  traces  of  ferrocyanide  are  then  washed  away.  That  this  has  been 
achieved  can  be  controlled  by  the  addition  of  a  few  drops  of  perchloride  of 
iron  solution  to  the  washings,  as  they  are  returned.  Any  trace  of  ferro- 
cyanide would  be  revealed  by  the  appearance  of  a  characteristic  colour 
(Prussian  blue). 

When  it  is  certain  that  the  washings  have  removed  all  the  reagent,  the 
patient  makes  water  into  three  glasses,  which  are  inspected  for  filaments. 
To  each  glass  a  little  perchloride  of  iron  is  added,  and  should  give  no  colour. 
A  blue  colour  would  indicate  that  some  of  the  ferrocyanide  has  passed  into 
the  posterior  urethra.  In  this  way  the  correctness  of  the  technique  can  be 
controlled. 

None  of  these  methods  permit  of  a  rigorous  distinction  between  the 
secretions  of  the  posterior  urethra  and  those  of  the  bladder  or  those  of  the 
prostate.     This  differentiation  is  possible  by  means  of  Wolbarst's  method. 

Wolbarst's  Method.-"- — Four  glasses  are  required,  and  one  proceeds  as 
follows  : 

1.  The  anterior  urethra  is  carefully  washed,  and  the  washings  are  col- 
lected in  the  first  glass;  they  represent  the  condition  of  the  anterior  urethra. 

2.  A  soft  catheter  is  passed  into  the  bladder,  and  the  pure  vesical  urine 
is  collected  in  the  second  glass. 

3.  The  bladder  is  now  washed  until  the  fluid  returns  clear.  It  is  then 
filled  with  water,  and  the  catheter  is  withdrawn. 

The  anterior  urethra  and  the  bladder  are  now  thoroughly  clean. 

4.  The  patient  now  passes  some  of  the  fluid  which  had  been  injected 

1  Abr.  L.  Wolbarst,  of  New  York,  Medical  Record,  April  21,  1906,  p.  627. 


90  GONOERHEA 

into  his  bladder  into  a  third  glass ;  this  lot  contains  anv  secretions  which  may 
come  from  the  posterior  urethra. 

In  this  way  the  secretions  from  the  three  parts  of  the  lower  urinary 
passages  are  separated. 

5.  The  prostate  is  massaged,  and  the  patient  makes  water  into  the  fourth 
glass,  the  contents  of  which  represent  the  prostate. 

The  author  of  this  process  has  never  found  it  to  fail,  and  he  considers  its 
indications  to  be  absolutely  accurate. 

There  is  no  doubt  that  these  various  methods  are  of  great  assistance  in 
complex  cases  which  require  special  accuracy,  but  for  ordinary  purposes 
they  are  too  tedious  and  too  complicated. 

The  Practical  Method. — ^In  most  cases  it  is  sufficient  to  ask  the  patient 
to  make  water  into  four  glasses.  One  can  thus  differentiate  with  sufficient 
accuracy  the  lesions  of  the  anterior  urethra  from  those  of  the  posterior. 
If  the  contents  of  the  first  glass  failed  to  cleanse  the  anterior  urethra,  those 
of  the  second,  and  a  fortiori  those  of  the  third,  will  do  so ;  and  if  the  fourth 
glass  contains  heavy  flakes,  whilst  the  second  and  third  do  not,  or  only 
contain  a  few,  then  the  diagnosis  of  posterior  urethritis  is  certain.  This 
simple  method  is  sufficiently  accurate. 

The  differentiation  between  the  anterior  and  the  posterior  urethra  is 
effected  in  this  method  by  the  second  and  third  glasses. 

The  types  most  commonly  observed  are  the  following : 

TFirst    glass  clear  or  turbid,   with  heavy  if.         .  ,       . 

I.    '      filaments;    second,    third,    and    fourth  UM^^erior^ urethritis  or 
[    glasses  clear,  without  filaments.  J       [     posterior  urethritis. 

fFirst  glass   clear  or  turbid,   with  heavy ^ 
J  J    J      filaments;    second    and    third    glasses 
I      clear,    without   filaments;  fourth  glass 
1^     clear  or  turbid,  with  heavy  filaments. 

f First  glass  clear,  with  a  few  heavy  fila-^ 
ments;  second  and  third  glasses  clear, 
with  a  few  or  no  filaments;  fourth 
glass  turbid,  with  heavy  filaments. 


J  Anterior  urethritis  and 
I      posterior  urethritis. 


III. 


.  J  Posterior    urethritis 
I      chiefly. 


Macroscopical  Examination  of  the  Filaments. — ^The  filaments  vary  in 
character,  and  should  be  examined  carefully.  Sometimes  they  are  very 
long,  mucous,  viscous,  and,  above  all,  light.  They  float  in  the  urine,  and  rise 
to  the  surface.  They  signify  irritation,  swperficial  congestion,  rather  than  a 
deeply-situated  lesion,  and  are  commonly  found  in  the  first  glass,  if  the  case 
has  been  treated  with  permanganate  irrigations.  These  are  the  light  or 
mucous  filaments. 

In  other  cases  the  filaments  are  thick,  heavy,  and  sinJc  rabidly  to  the 
bottom  of  the  glass.  They  always  contain  pus  cells,  and  are  indicative  of  a 
still  progressing  lesion ;  they  are  the  dangerous  filaments.     If  they  are  only 


THE  DIAGNOSIS  OF  URETHRITIS 


91 


found  in  the  first  glass,  tlie  anterior  urethra  alone  is  likely  to  be  affected. 
If  they  are  present  in  the  last  one  or  two  glasses,  and  have  the  shape  of  thick 
crumbs,  they  denote  a  lesion  of  the  posterior  urethra. 

Between  these  two  extreme  types  of  filaments  many  intermediate 
varieties  occur,  but  one  has  only  to  wait  a  few  moments  to  see  them  behave 
in  one  of  the  two  ways  described. 

Again,  the  filaments  may  be  comma-shaped.  According  to  Fiirbringer 
and  Finger,  these  special  filaments  are  derived  from  the  glandular  elements 
of  the  prostate,  which  are  moulded  upon  them,  and  these  authorities 
hold  that  their  presence  is  an  urgent 
indication  to  explore  the  prostate  per 
rectum. 

This  view  is  perfectly  correct,  but 
there  are  also  other  comma-shaped  fila- 
ments which  are  less  well  known,  and 
which  differ  not  only  in  their  aspect,  but 
also  in  their  origin,  from  them. 

These  filaments  resemble  a  well-made 
comma  or  a  well-shaped  crescent.  They 
are  slender,  and  contrast  by  their  lightness 
with  the  heavier  and  thicker  prostatic 
filaments.  Moreover,  they  are  only  found 
in  the  first  glass.  They  are  often  present 
in  large  numbers,  and  are  of  great  im- 
portance, because  they  are  an  almost 
infallible  sign  of  an  inflammation  of 
Littre's  glands. 


These  characteristic  filaments  origin- 


FiG.  34,  —  Suspended  in  the 
Urine:  Small,  Light,  Typical 
"  Comma -shaped"  Filaments, 
INDICATING  Lesions  oe  Littre's 
Glands. 


ate,  without  any  doubt,  in  the  glands  of 

Littre    which   are    found   in   the    penile 

urethra.     Whenever  this  diagnosis  can  be 

controlled  by  means  of  the  urethroscope, 

one   sees   that  the  orifices  of  these  glands   are  inflamed   {vide  Coloured 

Plate  III.,  Figs.  1,  2,  3,  4);  and  palpation  always  reveals  in  these  cases 

small  nodules  of  the  size  of  a  millet-grain  or  hempseed  along  the  under- 

surface  of  the  urethra  {vide  p.  100).     Lastly  there  is  the  therapeutic  proof. 

Under  a  rational  and  well-conducted  treatment  of  Littre's  glands,  these 

characteristic  filaments  disappear  as  the  littritis  subsides. 

Microscopical  Examination  of  the  Filaments. — This  examination  is 
essential  whenever  it  is  impossible  to  examine  the  discharge. 

One  is  thus  enabled  to  distinguish  the  microbic  elements  which  come 
from  the  balano-preputial  sulcus  and  from  the  meatus,  and  are  not  present 


.92  GONOERHEA 

in  the  urethra.  In  the  latter  case  there  are  no  organisms  in  the  filaments, 
even  if  the  microscope  had  shown  them  in  the  discharge  collected  from  the 
meatus. 

The  technique  is  very  simple.  With  a  platinum  loop  which  has  been 
passed  through  the  flame,  one  or  two  filaments  are  removed  from  the  urine 
and  placed  on  a  slide,  which  is  then  dried  in  a  current  of  air,  and  fixed  by 
being  passed  rapidly  through  a  Bunsen  flame  three  times.  It  is  then 
stained  by  one  of  the  methods  described  in  Chapter  III.  and  examined. 

Cultivation  of  the  Filaments. — ^When  there  is  no  discharge,  it  is  very 
often  important  to  know  if  the  filaments  are  quite  sterile.  This  is,  for 
instance,  the  case  if  the  patient  wishes  to  marry.  It  is  then  advisable  to 
cultivate  these  filaments ;  one  can  use  the  ordinary  media  for  this  purpose 
(agar,  gelatin,  or  broth),  but  it  is  preferable  to  inoculate  them  on  special 
media,  such  as  blood-agar  (Bezan9on  and  Griffon's  medium). 

2.  Examination  of  the  Urethra  Proper. 

The  examination  of  the  urethra  proper  consists  chiefly  in  the  study  of 
its  walls.  It  should  always  be  preceded  by  the  inspection  of  the  meatus 
and  of  the  prepuce. 

We  therefore  have  to  consider — 

1.  The  examination  of  the  meatus. 

2.  The  examination  of  the  prepuce. 

3.  The  exploratory  catheterization  of  the  urethra. 

1.  Examination  of  the  Meatus. 

The  meatus  requires  careful  inspection ;  in  the  same  way  as  the  tongue 
is  the  mirror  of  the  stomach,  the  meatus  is  "  the  mirror  of  the  urethral 
mucous  membrane." 

Red,  hyperemic,  and  edematous  lips  of  the  meatus  allow  one  to  suspect 
an  acute  and  recent  inflammation  of  the  canal.  On  the  other  hand,  if  the 
lips  are  bluish,  almost  dry,  or  scabbed  over,  or  stuck  together,  a  chronic 
condition  is  more  likely  to  be  present. 

One  should  also  note  if  the  shape  of  the  meatus  is  normal  or  not,  if  there 
is  epispadias  or  hypospadias,  and  if  diverticula  which  so  often  harbour 
gonococci  are  present. 

The  para-urethral  ducts  should  be  sought  for  carefully  in  the  neighbour- 
hood of  meatus  and  frenum.  Their  exploration  is  greatly  facilitated  by  the 
use  of  a  small  urethral  speculum  and  of  a  small  probe  with  which  they  can 
be  catheterized. 

These  flstulse  and  para-urethral  ducts  are  often  responsible  for  the 


THE  DIAGNOSIS  OF  UEETHRITIS 


93 


non-success  of  uretliro-vesical  irrigations  witli  antiseptic  solutions ;  the  latter 
simply  pass  over  them  without  entering  them. 

The  diverticula  which  are  visible  on  the  outside  have  been  well  described 
by  Janet. ^  They  are  relatively  easy  to  treat.  Those  which  are  situated 
inside  the  lumen  of  the  urethra  are  only  observable  with  the  aid  of  the 
urethroscope. 

The  former  variety,  which  may  be  termed  "  external,"  often  opens  by 
means  of  a  tiny  orifice  which  is  in  no  proportion  to  the  length  of  its  tract- 


Fig.  35.— Small  Urethral  Speculum  for  examining  the  Meatus. 

It  should  be  explored  with  a  stylet  ending  in  a  sharp  point,  and  not  with  a 
soft  bougie,  because  the  latter  lacks  the  necessary  resistance.  Another 
common  bulwark  of  micro-organisms  is  to  be  found  in  this  region — namely, 
Tyson's  glands.  When  these  para-urethral  ducts  are  infected,  they  can 
only  be  treated  successfully  and  cured  in  one  way :  by  opening  them  up  in 
their  whole  length. 

The  second  variety,  the  internal  fistulae,  is  common.  These  fistulae  are 
readily  seen  with  the  urethroscope,  and  demand  the  same  treatment  as  the 
external  variety. 


Fig.  36. — Small  Stylet  for  exploring  the  Para-Urethral  Ducts. 


One  should  not  restrict  the  examination  of  the  meatus  to  inspecting 
it  in  the  closed  condition.  The  lips  should  be  seized  between  thumb  and 
index,  and  be  separated.  One  is  thus  often  able  to  make  interesting  dis- 
coveries. For  instance,  a  youth  who  was  sent  to  me  by  Dr.  Barbier  showed 
nothing  abnormal  on  ordinary  inspection,  but  when  I  separated  the  lips  of  his 
meatus,  two  polypous  masses,  analogous  to  those  found  on  the  glans,  pro- 
jected, and  showed  us  that  he  was  suffering  from  a  polypous  urethritis. 

1  Janet,  "  Les  Repaires  Microbiens  de  I'Uretre,"  Annal.  des  Mai.  des  Organes 
Qenito-Urin.,  1902,  p.  897. 


94  GONOKKHEA 

2.  Examination  of  the  Peepuce. 

The  prepuce  should  be  drawn  back  completely  for  examination.  The 
balano-preputial  sulcus  is  cleansed  with  swabs  and  carefully  inspected. 
One's  attention  should  not  be  confined  to  its  state  of  inflammation;  but 
one  should  also  look  for  abnormal  or  inflamed  orifices,  such  as  the  openings 
of  Tyson's  glands,  already  alluded  to. 

The  length  of  the  prepuce  has  also  to  be  considered ;  a  prepuce  of  excessive 
length  favours  balanoposthitis,  and  often  keeps  up  a  chronic  urethritis  for 
a  considerable  time. 

3.  EXPLOEATORY  CaTHETEEIZATION  OF  THE  UeETHRA. 

The  exploratory  catheterization  of  the  urethra  is  carried  out  with  special 
bougies  which  have  an  olivary  end,  as  shown  in  Fig.  37.  They  should  be 
of  sufficient  length  to  reach  the  bladder,  and  of  such  rigidity  that  they  do 
not  curl  up  at  the  slightest  obstacle.  On  the  other  hand,  they  should  adapt 
themselves  easily  to  the  curves  of  the  urethra,  and  have  such  a  diameter 


Fig.  37. — Explobatory  Olivary  Bougie. 

that  they  are  not  in  actual  contact  with  its  walls.  The  terminal  olive  forms 
a  marked  projection  where  it  joins  the  stem  of  the  instrument,  a  kind  of 
heel. 

The  sizes  of  the  various  olives  are  measured  by  means  of  a  special  gauge^ 
{vide  Fig.  38). 

Contra-Indications  against  Instrumental  Examination  of  the  Urethra. — 
One  should  never  introduce  an  instrument  into  the  urethra  without  having 
examined  the  urine  previously,  which  should  be  passed  into  several  glasses. 
This  precaution  allows  one  to  avoid  serious  troubles,  because  the  passing  of 

1  The  gauge  used  is  the  ordinary  French  scale,  and  is  graduated  in  thirds  of  a 
millimetre.  Thus,  No.  1  is  J  millimetre  thick,  No.  12  equals  4  millimetres,  etc.  In 
addition  to  this  "  filiere  Charriere,"  there  is  the  "  fili^re  Guyon,"  which  is  graduated  in 
sixths  of  a  millimetre.  This  scale  was  introduced  by  the  late  Professor  Guyon,  and  is 
generally  used  for  dilators  and  other  metal  instruments.  The  equivalence  of  the  two 
scales  is  easily  calculated.  Guyon's  odd  numbers  have  no  equivalent  in  the  Charriere 
scale.  His  even  numbers  are  the  double  of  the  corresponding  numbers  of  the  ordinary 
gauge  ;  thus,  40  Guyon  equals  20  Charriere,  etc. 

For  genito-urmary  work  the  French  scales  are  preferable  to  the  English  catheter 
gauge,  as  Mr.  Reginald  Harrison  pointed  out  long  ago  (Surgical  Disorders  of  the  Urinary 
Organs,  J.  and  A.  Churchill,  1893).  I  have  therefore  thought  it  undesirable  to  compli- 
cate  the  text  by  giving  the  approximate  English  equivalents.  Where  reference  is 
made  to  Guyon's  scale,  a  G  has  been  added  (A.  F.). 


THE  DIAGNOSIS  OF  URETHRITIS 


95 


instruments  is  apt  to  lead  to  complications  when  the  urethra  is  acutely 
inflamed.  For  instance,  if  the  posterior  urethra  be  healthy,  whilst  the 
anterior  portion  is  inflamed,  an  instrument  can  easily  convey  organisms 
from  the  latter  to  the  former,  and  thus  infect  it. 

In  practice  one  should  therefore  be  guided  by  the  principle  that  a 
patient  whose  first  glass  of  urine  is  turbid  should  not  be  treated  with  instru- 
ments, even  if  the  second  one  be  clear.  In  a  case  of  this  kind,  diffuse  and 
recent  superficial  lesions  are  present,  which  hasty  and  untimely  manipulations 
would  probably  aggravate. 

When  the  urine  is  clear,  and  contains  but  filaments — i.e.,  when  the 
lesions  are  localized — then,  and  only  then,  can  instrumental  examination  of 
the  urethra  be  carried  out  without  any  risk. 

Technique. — For  a  urethra  which  one  has  never  explored  before,  it  is 
best  to  take  an  exploratory  bougie  (No.  18).     The  meatus  and  the  anterior 


Fig.  38. — French  Catheter  Scale  (Filiere  Charribre). 


urethra  are  washed,  and  it  is  wise  to  allow  a  little  boric  solution  to  run  into 
the  bladder  from  an  irrigator.  A  catheter  should  not  be  used  in  filling  the 
bladder. 

The  lubricated  exploratory  bougie  is  then  placed  against  the  meatus 
with  the  right  hand,  whilst  the  left  one  stretches  the  penis  somewhat.  The 
olivary  end  is  then  gently  passed  into  the  meatus  by  means  of  a  slight 
rotatory  movement,  and  pushed  onwards.  In  a  healthy  urethra  the  instru- 
ment advances  without  diflS.culty,  and  without  causing  any  pain,  until  the 
membranous  urethra  is  reached.  Here  the  olive  meets  with  an  obstacle 
which  is  physiological,  and  is  present  in  every  urethra.  It  is  indispensable 
to  inform  the  patient  of  this  fact.  By  so  doing  one  saves  him  the  surprise 
of  an  unexpected,  disagreeable,  and  painful  sensation,  and  enables  him  to 
assist  matters  by  trying  to  relax  his  sphincter,  as  if  he  were  about  to  make 
water,  or  by  letting  himself  go,  taking  deep  breaths,  as  if  he  were  fast  asleep. 
In  most  cases  the  sphincter  is  thus  overcome;  the  instrument  passes  over 
the  prostate  and  enters  the  bladder,  where  it  becomes  freely  movable. 


96 


GONORRHEA 


But  before  it  glides  past  the  neck  of  the  bladder  tbe  olive  always  gives 
a  little  "  jerk,"  as  Lallemand  pointed  out  as  far  back  as  1836.  This  is  due 
to  the  presence  of  the  verumontanum,  which  projects  into  the  lumen  of  the 
urethra,  and  thus  forms  a  slight  obstacle.  Normally  this  structure  is  almost 
void  of  sensation,  but  when  it  is  chronically  inflamed  it  occasionally  becomes 
exceedingly  tender.  The  passage  of  an  instrument  is  then  horribly  painful, 
and  throws  the  patient  into  the  position  of  opisthotonos  as  long  as  the 
instrument  remains  in  contact  with  his  verumontanum.  In  cases  of  chronic 
posterior  urethritis,  and  in  nervous  subjects,  one  also  meets  with  instances 


FiG.  39. — Exploratory  Catheterization  op  the  Urethra. 


in  which  the  bougie  will  not  pass;  the  sphincter  is  firmly  contracted, 
in  a  state  of  spasm,  although  the  patients  may  do  their  best  to  assist  the 
intervention. 

When  such  spasm  is  present,  the  following  simple  remedy  may  be  tried  : 
One  presses  the  bougie  gently  against  the  sphincter  with  the  right  hand, 
whilst  the  left  hand  draws  the  penis  upwards.  By  this  means  one  prevents 
the  olive  from  being  caught  in  a  fold  of  mucous  membrane  instead  of  the 
sphincter. 

This  procedure  is  often  of  no  avail,  and  the  sphincter  remains  so  tightly 
contracted  that  nothing  can  pass. 

Then  one  may  try  a  thin,  more  rigid  bougie,  which  may  take  the 
sphincter  by  surprise  and  pass  it.  This  method  is  often  successful,  and 
allows  one  to  pass  the  olivary  bougies  subsequently. 

Or  one  may  anesthetize  the  sphincter  with  stovain.     For  this  purpose, 


THE  DIAGNOSIS  OF  URETHRITIS  97 

either  an  instillation  of  a  few  drops  of  a  1  per  cent,  solution  is  made  just 
in  front  of  the  sphincter,  or  the  anterior  urethra  is  filled  with  10  c.c.  of  this 
solution,  which  is  allowed  to  act  for  a  few  minutes. 

Lastly,  another  means  consists  in  passing  a  large  metal  sound  (No.  40  G 
or  No.  42  G). 

This  last  method  is  as  a  rule  the  most  likely  one  to  prove  successful. 
In  one  of  my  cases,  for  instance,  the  patient,  a  young  man  of  twenty-seven, 
had  a  chronic  urethritis,  and  was  able  to  pass  his  water  without  any  diffi- 
culty. His  sphincter,  however,  contracted  firmly  every  time  an  instrument 
came  into  touch  with  it.  First  a  filiform  bougie  was  stopped,  and  the  spasm 
of  the  sphincter  was  accompanied  by  spasmodic  contractions  of  his  right 
femoral  triceps.  Then  instillations  of  cocain  proved  useless.  Finally  a 
sound  was  introduced;  it  passed  easily  along  the  anterior  urethra,  but  as 
soon  as  it  reached  the  sphincter  the  patient  had  a  seizure,  which  compelled 
me  to  remove  the  instrument  speedily.  However,  a  second  attempt  was 
made,  after  he  had  quieted  down,  and  this  time  the  sound  entered  with  the 
greatest  ease. 


Fig.  40. — Curved  Metal  Sound  (Benique  with  Guyon's  Curve). 

At  all  events  the  membranous  sphincter  is  a  fixed  and  precious  landmark 
which  allows  one  to  locate  any  abnormal  sensations  which  may  be  felt  whilst 
the  exploratory  catheter  is  being  passed.  For  further  precision  one  should 
use  the  touch.  The  relief  formed  by  the  olive  should  be  felt  through  the 
integuments,  and  this  is  easy  if  one  moves  the  instrument  gently  to  and  fro. 
In  this  way  a  lesion  can  be  accurately  located. 

Generally  speaking,  exploration  of  the  urethra  by  means  of  the  olivary 
bougie  is  most  useful.  This  instrument  is  really  a  continuation  of  the 
palpating  finger;  it  allows  one  to  feel  any  changes  in  the  lumen  of  the 
passage,  and  to  locate  the  lesions  present  fairly  accurately. 

Results  obtained  by  the  Exploratory  Catheterization  of  the  Urethra. — 
1.  This  method  of  examination  is  especially  useful  in  chronic  urethritis. 
The  patches  of  induration  and  of  infiltration  which  develop  in  the  course 
of  this  affection  are  detected  by  the  olivary  bougie,  and  hence  the  suitable 
treatment  is  indicated. 

Some  of  these  patches  are  almost  imperceptible,  the  so-called  wide 
strictures,  and  should  always  be  looked  for  with  great  care.     It  is  often 

7 


<Sii= 


98  GONOEKHEA 

necessary  to  use  a  bougie  (No.  20,  or  even  25  or  27)  for  their  detection,  if 
the  smaller  instruments  do  not  allow  one  to  feel  them. 

The  exploratory  bougie  should  be  introduced  slowly,  and  any  sensations 
of  roughness  or  hardness  of  the  urethral  walls  should  be  carefully  noted. 
Once  the  instrument  has  traversed  the  entire  canal,  it  is  gently  withdrawn. 
This  withdrawal  is  of  special  importance,  because  the  heel  of  the  olive  knocks 
up  against  the  slightest  obstacle,  and  thus  gives  valuable  information. 

One  often  notices,  whilst  the  instrument  is  being  withdrawn,  uneven  or 
rough  places  immediately  in  front  of  the  sphincter.  Or  the  heel  of  the  olive 
is  stopped  in  its  course  by  a  small,  more  or  less  complete  ring  in  the  perineal 
or  scrotal  portion. 

There  are  cases  in  which  even  a  large  explorator  reveals  nothing  when 
one  moves  it  about  very  slowly.  It  is  then  advisable  to  move  it  quickly 
like  the  bow  of  a  violin.  Occasionally  a  roughness  which  would  not  be 
noticed  otherwise,  is  detected  in  this  way.  One  should  therefore  combine 
the  different  modes  of  passing  an  olivary  bougie.  In  all  cases,  however, 
the  manipulations  should  be  carried  out  with  gentleness. 


Fig.  41. — HAMOisric's  Ubethrograph.i 

It  is  very  important  to  discover  the  presence  of  any  wide  strictures,  and 
to  locate  them.  They  are  very  common  in  chronic  urethritis,  and  require  a 
different  therapy  according  to  their  position. 

2.  The  olivary  bougie  is  especially  useful  for  exploring  strictures  of  the 
urethra.  The  latter  are  often  multiple,  and  are  best  examined  with  a  some- 
what large  bougie,  say  No.  20.  If  one  proceeds  differently,  and  takes  a 
smaller  olive,  one  is  apt  to  overlook  those  present  in  the  penile  portion,  and 
to  recognize  only  those  which  are  farther  back — for  instance,  those  of  the 
perineal  portion. 

One  notes,  to  begin  with,  the  exact  point  at  which  an  olive  (No.  20) 
stops,  takes  a  smaller  one,  say  18  or  15,  and  notes  again  where  this  instru- 
ment meets  with  an  obstacle.  In  this  way  one  proceeds,  using  smaller  and 
smaller  bougies,  until  one  of  them  reaches  the  bladder.  When  the  olive  is 
withdrawn,  the  heel  is  caught  at  the  various  strictures,  and  gives  each  time 
a  characteristic  jerk.  By  this  means  one  is  enabled  to  make  out  the  exact 
number  of  the  strictures  present,  their  size  and  their  exact  position.  An 
interesting  instrument,  which  gives  a  graphic  record  of  the  strictures  found, 
is  Hamonic's  urethrograph  (Fig.  41). 

3.  The  exploration  of  the  antero-posterior  measurement  of  the  prostate  is 
1  Hamonic,  "  Nouvel  Uretrographe,"  Ass.  Frangaise  d'Urologie,  1906,  p.  234. 


THE  DIAGNOSLS  OF  UEETHRITIS  99 

possible  within  limits  by  means  of  the  olivary  bougie.  For  this  purpose  an 
instrument  (No.  20)  is  passed  into  the  bladder;  it  is  then  gently  withdrawn 
until  one  feels  a  very  slight  resistance,  which  indicates  the  neck  of  the 
bladder.  The  point  on  the  stem  which  is  now  in  contact  with  the  meatus 
is  noted,  and  the  bougie  is  again  slowly  withdrawn  until  the  olive  loses  touch 
with  the  membranous  sphincter.^  By  measuring  the  distance  on  the  stem 
between  the  point  marked  and  the  point  which  now  corresponds  to  the 
meatus,  the  length  of  the  prostatic  urethra  is  found. 


Fig.  42. — Exploration  of  the  Antero-Postebior  Measurement  of  the 
Prostate  by  Means  op  the  Olivary  Bougie. 

4.  The  olivary  bougie  is  also  a  useful  instrument  for  diagnosing  the 
seat  of  foreign  bodies  in  the  urethra,  whether  they  be  calculi,  or  pieces  of 
a  broken  catheter,  or  articles  which  have  been  introduced  for  inadmissible 
reasons. 

3.  Examination  of  the  Glands  connected  with  the  Urethra. 

The  exploration  of  the  glands  which  are  connected  with  the  urethra  is  at 
least  as  important  as  the  examination  of  the  canal  itself.  They  often 
harbour  gonococci,  and  are  therefore  largely  responsible  for  the  exasperating 
tenacity  of  gleet. 

1  As  a  rule  this  can  be  felt  without  difficulty. 


100  GONORRHEA 

In  the  same  way  as  Ricord  "  felt  the  pulse  of  syphilis,"  we  should  nowa- 
days be  able  to  "  feel  the  pulse  of  gonorrhea."^ 

A  methodical  exploration  of  the  urethral  glands  comprises  the  following 

glands : 

Littre's  glands. 

Cowper's  glands. 

The  prostate. 

The  seminal  vesicles. 

1.  Exploration  op  Littee's  Glands. 

The  glands  of  Littre,  which  are  found  in  the  mucosa  of  the  anterior 
urethra,  represent  its  glandular  apparatus,  and  are  very  important,  as  they 
are  one  of  the  chief  factors  which  prolong  discharges  from  the  urethra. 
When  infected  they  form,  together  with  the  lacunae  of  Morgagni,  hiding- 
places  for  the  gonococci,  which  are  shut  off  by  plugs  of  mucus.  They  only 
empty  their  contents  into  the  urethra  at  odd  intervals,  and  are  practically 


Fig.  43. — Stbaight  Metal  Sound.     (Benique.) 

unafEected  by  irrigations,  instillations,  and  injections.  The  fluids  used  in 
these  different  therapeutic  procedures  merely  pass  over  the  general  surface 
of  the  mucosa,  but  do  not  enter  the  crypts  of  these  glands. 

A  focus  of  this  type  is  thus  apt  to  give  rise  to  a  series  of  successive 
reinfections,  which  are  most  exasperating  for  the  patient  and  his  surgeon. 
Continued  recurrences  are  the  rule,  even  when  a  well-conducted  irrigation 
treatment  seemed  to  justify  the  hope  of  curing  the  discharge  completely. 

For  the  examination  of  Littre's  glands  two  methods  should  be  used : 

1.  Urethroscopy,  which  enables  one  to  see  the  orifices  of  these  glands. 
We  merely  mention  it  here,  because  this  diagnostic  method  is  described 
fully  in  the  following  chapter. 

2 .  Palpation  of  the  Urethra,  which  gives  a  rough  idea  of  the  volume,  shape, 
and  number,  of  the  glands  involved. 

Palpation  of  the  Urethra. — The  credit  of  having  pointed  out  the  value 
of  this  diagnostic  method  belongs  to  Motz,  who  described  it  fully  in  1901.2 

It  is  useless  to  try  to  palpate  the  urethra  without  the  assistance  of  an 
instrument.  The  introduction  of  as  large  a  benique  as  possible  is  essential. 
This  method  should  be  reserved  for  cases  in  which  all  acute  inflammation  has 
disappeared,  and,  when  possible,  it  should  only  be  resorted  to  after  the  first 
glass  of  urine  has  become  clear. 

1  Luys,  "  Comment  on  tate  le  Pouls  a  la  Blennorragie,"  La  Clinique,  April  13, 1906. 

2  Motz,  Comptes  Eendus  de  VAss.  Frang.  d'Urologie,  1901,  p.  219. 


THE  DIAGNOSIS  OF  UEETHEITIS 


101 


The  examination  itself  is  carried  out  by  introducing  a  large  straight 
sound,  at  least  No.  40  Gr,  into  the  anterior  urethra,  seizing  the  penis  with 
the  left  hand,  and  stretching  it  on  the  instrument.     With  the  first  fingers 


Fig.  44. — Palpation  of  the  Urethba  :  Seabching  fob  Chronically  Inflamed 

Glands  op  Littbe. 


of  the  right  hand  one  now  palpates  carefully  the  wall  of  the  urethra  {mde 
Fig.  44).  If  this  palpation  reveals  the  presence  of  small  nodules  of  the 
size  of  a  millet-grain  or  of  a  hempseed,  one  may  be  certain  that  they 
represent  diseased  areas  which  shelter  gono cocci  and  keep  up  the  illness. 


102  GONORRHEA 

It  is  highly  advisable  to  make  this  examination  in  all  cases  of  chronic 
urethritis,  because  it  allows  one  to  detect  one  of  the  most  common  localiza- 
tions of  chronic  discharges. 

It  is,  however,  well  to  remember  that  the  upper  urethral  wall  is  not 
accessible  to  the  touch,  because  it  is  covered  by  the  corpora  cavernosa. 
Only  three-quarters  of  the  circumference  can  be  explored  by  this  method, 
and  therefore  urethroscopic  examination  must  be  resorted  to  in  order  to 
render  the  investigation  complete. 

2.  Examination  of  Cowper's  Glands. 

The  glands  of  Cowper  are  mucous  glands  which  are  connected  with  the 
urethra,  and  are  situated,  according  to  most  anatomists,  within  the  muscles 
of  the  urogenital  diaphragm.  They  are  two  in  number,  and  open  on  the 
inferior  surface  of  the  bulb  by  two  ducts  on  either  side  of  the  middle  line. 
They  have  been  carefully  studied  recently  by  Dr.  Hogge  of  Liege,  to  whose 
writings  the  reader  may  be  referred  for  further  information.^ 

These  glands  are  often  infected  in  the  course  of  gonorrhea,  and  therefore 
their  examination  should  be  a  matter  of  routine.  Their  inflammation  does 
not  give  rise  to  any  special  symptoms,  and  is  apt  to  be  overlooked. 

For  the  exploration  of  these  glands  the  patient  should  lie  flat  on  his  back, 
the  thighs  and  legs  being  semiflexed,  with  the  heels  together  and  the  knees 
separated.  It  is  well  to  place  a  cushion  under  the  pelvis.  One  lifts  up  the 
scrotum,  and  explores  carefully  the  perineum  by  inspection  and  palpation. 

In  some  cases  one  finds  a  small  swelling  of  the  size  of  a  pea  or  of  a  cherry, 
which  is  tender  on  pressure.  It  lies  to  one  side  of  the  middle  line,  close  to 
the  anus,  and  is  covered  by  hot,  tense,  red  skin.  The  diagnosis  of  cowperitis 
is  then  almost  obvious,  but  more  often  nothing  abnormal  is  detected ;  the 
skin  of  the  perineum  is  smooth,  white,  and  normal. 

Digital  examination  should  then  be  resorted  to  in  order  to  ascertain  if 
the  inflammatory  swelling  is  not  connected  with  the  prostate.  This 
exploration  should  be  hidigital,  and  be  made  in  the  following  way:  The 
index  of  the  right  hand  is  introduced  into  the  anus,  with  its  pahnar  surface 
directed  towards  the  urethra.  After  having  passed  the  anal  sphincter,  the 
finger  hooks  forwards  at  the  beak  of  the  prostate.  Its  pulp  then  touches 
the  bulb  of  the  urethra,  and  at  the  same  time  the  right  thumb  presses  on 
the  skin  of  the  perineum  to  one  side  of  the  median  raphe,  and  tries  to  meet 
the  pulp  of  the  index  [vide  Fig.  45). 

If  one  feels  between  the  index,  in  the  rectum,  and  the  thumb,  on  the 
perineum,  a  small  swelling  of  the  size  of  a  large  pea,  which  is  definitely  pain- 
ful, one  may  be  certain  that  one  is  dealing  with  an  inflamed  Cowper's  gland, 

^  Hogge,  "  Recherches  sur  les  Muscles  du  Perinee  et  du  Diaphragme  Pelvien,"  AnnaL 
des  Mai.  des  Organes  Genifo-Urin.,  July  15,  August  1  and  15,  1904. 


THE  DIAGNOSIS  OF  URETHRITIS 


103 


as  this  organ  is  insensitive  in  its  normal  state.     This  examination  should,  of 
course,  be  made  on  both  sides  of  the  middle  line. 


Fig.  45. — Bidigital  Palpation  of  Cowper's  Glands. 
The  affected  gland  is  felt  between  the  index,  in  the  rectum,  and  the  thumb,  on 

the  perineum. 

Once  the  'bidigital  examination  has  shown  that  one  of  Cowper's  glands 
is  enlarged  and  inflamed,  the  exploration  should  be  completed  by  expressing 
its  contents.     For  this  purpose  the  patient  should  first  make  water,  and  then 


104  GONOHKHEA 

have  his  bladder  filled  with  boric  lotion.  One  now  massages  the  diseased 
gland,  or  glands,  taking  care  not  to  touch  the  prostate,  and  asks  the  patient 
to  pass  the  boric  lotion  into  several  glasses.  The  contents  of  the  inflamed 
Cowper's  glands  fall  into  the  first  glass;  they  are  separated  by  means  of 
the  centrifuge,  and  then  carefully  examined  under  the  microscope. 

In  most  cases  this  modus  operandi  is  successful,  but  there  are  instances 
in  which  even  the  most  energetic  attempts  at  massage  and  expression  fail 
to  empty  the  inflamed  glands,  and  merely  cause  severe  pain.  One  is  then 
confronted  with  an  obstruction  of  their  duct,  or  ducts,  which  one  should 
try  to  open  by  means  of  urethral  dilatation.  These  dilatations  should  be 
carried  out  methodically  and  pushed  very  far.  If  they  fail,  it  becomes 
necessary  to  extirpate  the  gland  through  an  incision  in  the  perineum. 

3.  Exploration  of  the  Prostate. 

The  prostate  is  the  largest  gland  connected  with  the  urethra,  and  is, 
owing  to  its  situation,  frequently  implicated  in  infections  of  the  urethra 
and  of  the  bladder.  Its  examination  is  therefore  indispensable  in  a  great 
number  of  urinary  affections. 

Several  methods  are  at  our  disposal,  which  we  will  briefly  indicate  and 
consider — ^namely : 

1.  Rectal  palpation. 

2.  Expression  ("  milking  ")  of  the  organ. 

3.  Exploration  by  means  of  an  olivary  bougie. 

4.  Exploration  by  means  of  a  bladder  sound. 

5.  Urethroscopy. 

6.  Cystoscopy. 

1.  Rectal  Palpation. — The  palpation  of  the  prostate  per  rectum  is  mainly 
destined  to  give  information  as  to  the  shape,  the  consistence,  and  the  volume 
of  the  organ.    It  can  be  well  carried  out  in  the  horizontal  position. 

Technique. — ^It  is  advisable  to  let  the  patient  make  water  into  four 
glasses,  which  are  examined  subsequently,  and  to  fill  his  bladder  with  boric 
solution  from  an  irrigator.  The  secretions  which  are  expressed  from  the 
organ  by  the  palpating  finger  can  thus  be  washed  away  by  a  slightly  anti- 
septic fluid.  In  this  way  they  are  rendered  innocuous,  and  can  be  examined, 
once  the  rectal  examination  is  terminated  and  the  patient  empties  his 
bladder. 

The  patient  should  lie  flat,  with  his  legs  apart  and  slightly  flexed,  and 
his  pelvis  raised  by  means  of  a  cushion.  The  index,  after  having  been 
protected  by  a  finger-stall,  is  well  lubricated,  and  introduced  into  the  rectum. 
One  palpates  methodically  the  prostate,  first  its  beak,  then  its  lateral  lobes, 
and  finally  its  middle  portion.  One  thus  becomes  acquainted  with  its  size, 
shape,  consistence,  and  also  its  degree  of  tenderness.     One  determines  whether 


THE  DIAGNOSIS  OF  URETHRITIS 


105 


the  pain  experienced  by  the  patient  is  due  to  the  prostate  or  to  the  posterior 
urethra,  by  palpating  alternately  the  lateral  lobes  and  the  middle  line. 
Pain  along  the  latter  is  connected  with  the  urethra,  especially  with  the 
verumontanum,  whilst  any  pain  felt  laterally  is  due  to  the  prostate. 

Indications  for  Rectal  Examination. — This  method  of  examination  is 
required  in  the  course  of  every  inflammation  of  the  urethra.  In  chronic  cases 
it  allows  one  to  tell  if  the  prostate  is  afTected,  and  if  it  contains  a  focus 
which  is  prolonging  the  illness.  Carried  out  early  in  acute  cases  of  gonorrhea, 
it  enables  one  to  find  out  if  the  posterior  urethra  is  being  invaded  by  the 
gonococci  almost  as  soon  as  this  takes  place. 


Fig.  46. — Rectal  ExAMiNATioisr  of  the  Prostate. 

The  figure  shows  that  the  finger  in  the  rectum  barely  reaches  the  lower  end  of  the 
seminal  vesicle  in  the  horizontal  position.  For  the  examination  and  expression  of 
these  organs  the  position  indicated  in  Fig.  47  is  required. 


2.  Expression  (Milking)  of  the  Prostate. — By  this  procedure  the  contents 
of  the  gland  and  the  'prostatic  secretions  are  examined. 

Technique. — The  patient  should  first  make  water;  this  safeguards  against 
mistakes,  such  as  attributing  to  the  prostate  the  purulent  debris  which  his 
urine  may  contain,  and  which  really  comes  from  the  kidneys,  or  the  bladder, 
or  the  urethra.     The  patient  is  then  irrigated  until  the  washings  are  returned 


106 


GONORRHEA 


quite  clear,  and  the  urethra  is  cleansed  thoroughly.  Once  this  has  been 
done,  the  bladder  is  filled  with  boric  solution,  and  the  patient  places  himcelf 
in  the  proper  position  for  massage.  He  should  be  standing  firmly,  with  his 
body  bending  forwards,  and  his  elbows  resting  on  a  firm  support,  such  as 
a  couch.  With  one  hand  he  holds  a  glass  under  the  meatus,  in  which  the 
prostatic  secretion  is  collected  for  examination. 


Fig.  47. — Expbession  of  the  Prostate. 

The  prostatic  secretion  is  collected,  in  a  glass  \vhich  has  teen  half  filled  with  water. 
The  flakes  of  pus  are  thus  more  easily  differentiated  from  the  normal  prostatic 
fluid,  which  is  opalescent. 

The  surgeon  then  covers  his  fingers  with  vaseline,  introduces  it  into  the 
rectum,  and  makes  for  the  prostate.  He  presses  on  the  lobes  of  the  gland, 
and  expresses  their  contents,  which  pass  into  the  urethra,[and  then  into  the 
glass  kept  ready  for  them.    In  cases  of  intraprostatic  abscess,  the  finger 


THE  DIAGNOSIS  OF  URETHRITIS  107 

often  feels  a  soft  area  which  yields  to  it,  and  retains  the  mark  of  the  finger. 
The  sensation  experienced  frequently  in  these  instances  has  been  compared 
by  Gruyon  with  that  felt  by  a  finger  "  when  it  presses  on  a  supple  cloth 
stretched  on  a  frame." 

Some  patients  find  the  first  sittings  very  painful,  and  may  even  faint. 
It  is  therefore  advisable  to  proceed  gently  and  slowly  at  first.  As  the 
patients  become  more  accustomed,  the  treatment  should  gradually  become 
more  energetic. 

After  the  massage  the  patient  empties  the  boric  solution,  which  had 
been  run  into  his  bladder,  into  four  glasses.  In  this  way  one  can  examine 
the  debris  removed  from  the  prostate  by  the  massage. 


Fig.  48. — Feleki's  Instrument  for  Prostatic  Massage. 

The  digital  method  just  described  is  the  best,  and  none  of  the  instruments 
devised  for  the  purpose,  such  as  Feleki's  instrument  (Fig.  48),  are  equal  to 
the  finger. 

Indications. — The  prostate  should  be  massaged  whenever  one  suspects 
it  of  containing  pus  or  retention  products.  The  secretions  should  always  be 
microscoped,  as  valuable  diagnostic  information  is  obtained  in  this  way. 
It  is  therefore  indicated  in  all  cases  of  prostatitis.^ 

The  following  figures,  which  have  been  taken  from  Oberlander  and  Koll- 
mann's  work,^  show  the  different  microscopical  findings  in  the  various 
degrees  of  prostatic  inflammation. 

Very  valuable  researches  on  this  subject  have  also  been  carried  out  by 
Dr.  Ernst  Frank,  of  Berlin,  who  found  the  gonococcus  in  179  cases  out  of 
210;  20  contained  other  organisms,  and  11  had  an  aseptic  secretion.^ 

3.  Exploration  by  Means  of  the  Olivary  Bougie. — This  method  is  really 
an  intra'prostatic  palpation  (Guyon). 

Technique. — The  bladder  having  been  filled  with  boric  lotion,  the  olivary 
bougie  is  passed  as  far  as  the  membranous  urethra.     The  prostatic  portion 

1  Vide  on  this  point:  Maurice  Picot,  Le  Massage  de  la  Prostate  (Thesis,  Paris,  1906). 
^  Kollmann  and  Oberlander,  Die  Chronische  GonorrJioe,  1901,  Leipzig. 
^  Frank,    "  Die  Gonorrhoische    Erkrankung  der   Vorsteherdriise,"    Monatschr.  f. 
H  arnkrankh.  und  Sexudle  Hyg.,  1906,  fasc.  1. 


108 


GONOERHEA 


is  then  explored,  and  one  notes  carefully  the  curves  of  the  passage,  the 
extent  to  which  its  lower  wall  projects,  the  degree  of  tenderness  of  the 
verumontanum,  the  length  of  the  prostatic  urethra,  and  any  deviations  of 
its  course. 


Fig.  49. — Normal  Prostatic  Secretion 
UNDER  THE  MICROSCOPE.  (Oberlander 
and  KoUmann.) 

Ef.,  Prostatic  epithelium;  Kr.,  sperm- 
acetin  crystals;  Corp.  am.,  corpora 
amylacea;  Lee.  k.,  lecithin  globules. 


Fig.  50. — Secretion  in  Acute  Prostatic 
Inflammation  under  the  Micro- 
scope.    (Oberlander  and  Kollmann.) 

Leuk.,  Leucocytes  ;  Lee.  k.,  lecithin 
globules ;  Ep.,  prostatic  epithelium. 


Fig.  51. 


-Secretion  in  Mild  Prostatic  Inflammation  under  the  Micro- 
scope.    (Oberlander  and  Kollmann.) 

Leuk.,  Leucocytes ;  Lee.  k.,  lecithin  globules. 


The  amount  of  congestion  can  also  be  made  out  by  this  method.  If  the 
instrument  is  gently  and  carefully  introduced,  and  the  urethra  begins  to 
bleed,  one  is  entitled  to  conclude  that  the  prostate  is  friable  and  intensely 
congested  (Guyon). 


THE  DIAGNOSIS  OF  URETHRITIS 


109 


Lastly,  this  method  enables  one  to  measure  the  length  of  the  prostatic 
channel,  as  pointed  out  above  (p.  99). 

4.  Exploration  by  Means  of  a  Bladder  Sound. — By  means  of  a  rigid  metal 
instrument  one  is  able  to  judge  how  far  the  prostate  gland,  and  especially  its 
middle  lobe,  projects  into  the  interior  of  the 
bladder.  Moreover,  information  is  also  gained 
as  to  the  depth  of  the  fundus  of  the  bladder, 
and  this  is  often  of  considerable  importance. 

5.  Urethroscopic  Examination. — The  ex- 
amination of  the  prostatic  portion  of  the 
urethra  by  means  of  the  urethroscope  gives 
but  little  information  on  the  condition  of 
the  prostate  itself.  The  endoscopic  tubes 
only  permit  one  to  see  the  superficial  parts 
of  the  prostatic  urethra;  hence  the  veru- 
montanum  and  the  prostatic  lacunae  are  the 
only  parts  which  are  explorable  by  this 
method,  but  they  are  very  clearly  visible. 

Urethroscopic  examination  of  the  pros- 
tate is  of  considerable  value  in  cases  of 
chronic  posterior  urethritis  which  resist 
ordinary  treatment.  It  should  be  complete 
in  all  cases — i.e.,  the  urethroscopic  tube 
should  explore  methodically  and  slowly  the 
whole  urethra  between  the  neck  of  the 
bladder  and  the  membranous  sphincter.  It 
is  a  great,  and  unfortunately  common,  mis- 
take to  urethroscope  only  as  far  as  the 
verumontanum.  It  is  indispensable  to  in- 
clude in  the  examination  the  important 
region  between  the  neck  of  the  bladder  and 
the  verumontanum,  which  is  known  as  the 
"prostatic  jossette  (Fig.  108). 

6.  Cystoscopic  Examination  of  the  Pros- 
tate.— In  order  to  get  a  clear  picture  of  the 
relief  produced  in  the  bladder  by  an  enlarged 
prostate,  cystoscopic  examination  should  be 
resorted  to.  One  of  the  best  instruments 
for  the  purpose  is  Schlaginweit's  retrograde  cystoscope.  It  gives  a  clear  view 
of  the  whole  circumference  of  the  neck  of  the  bladder,  and  shows  accurately 
any  intravesical  bulging  of  the  prostate,  if  present.^ 

^  Vide  Luys,  Exploration  de  VAppareil  Urinaire,  Paris  (Masson),  p.  176,  for  further 
details. 


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no  GONOREHEA 

4,  The  Examination  of  the  Seminal  Vesicles. 

The  examination  of  these  organs  is  also  of  great  importance,  and  is 
carried  out  by  means  of — 

1.  Palpation  per  rectum. 

2.  Expression  of  the  vesicles. 

3.  Urethroscopy. 

1.  Palpation  per  Rectum. — The  method  for  examining  the  seminal 
vesicles  is  similar  to  the  one  used  for  the  prostate  {vide  p.  106).  The  index 
is  completely  introduced  into  the  rectum,  and  passed  over  the  prostate. 
One  then  feels  above  and  behind  the  lobes  of  this  gland  a  long,  hard,  some- 
times doughy,  body,  which  is  the  seminal  vesicle.  The  shape  of  the  inflamed 
vesicle  corresponds  more  or  less  to  that  of  the  organ  during  health,  and 
depends  largely  on  the  amount  of  'perivesicular  inflammation  present.  This 
involvement  of  the  surrounding  cellular  tissue  is  seldom  wanting.  A 
healthy  seminal  vesicle  is  much  more  difficult  to  feel,  and  in  certain  cases 
it  is  impossible  to  distinguish  it  from  the  neighbouring  tissues.  This  is 
notably  true  if  the  vesicle  has  been  emptied  recently  by  coitus. 

These  organs  should  always  he  explored  in  the  course  of  an  attack  of 
go'norrhea,  because  their  invasion  by  the  gonococcus  is  usually  accompanied 
by  symptoms  so  vague  and  obscure  that  their  infection  escapes  notice,  unless 
one  makes  a  point  of  examining  the  seminal  vesicles  in  all  cases  of  posterior 
urethritis.^ 

The  signs  which  allow  one  to  tell  that  a  seminal  vesicle  is  affected  are 
the  following : 

(1)  Pain  on  Pressure. — In  most  cases  there  is  a  marked  difference 
between  the  two  sides  in  this  respect. 

(2)  The  Difference  in  Size,  which  is  usually  dependent  on  the  presence 
of  a  concomitant  perivesicular  inflammation. 

(3)  The  Difference  in  Consistency. — One  occasionally  meets  with  diffuse 
indurations  which  are  so  marked  that  they  simulate  a  cancerous  infiltration 
of  the  bladder. 

2.  Expression  of  the  Seminal  Vesicles. — The  technique  is  practically 
the  same  as  for  the  prostate.  It  is,  however,  necessary  to  pass  the  index 
as  far  as  possible  beyond  the  prostate,  and  then  to  bring  it  gradually  down 
again  to  this  gland.  The  upright  position,  with  the  body  leaning  forwards, 
described  above  (p.  106),  is  absolutely  essential,  as  it  is  the  only  one  which 
enables  the  surgeon  to  reach  these  organs  and  to  massage  them  properly — 
namely,  from  above  downwards.  The  vesicles  and  the  ejaculatory  ducts 
can  be  emptied  in  this  manner  into  a  glass  held  in  front  of  the  meatus. 

1  And  also  because  tlie  seminal  vesicles  are  the  usual  starting-point  of  a  generalized 
gonococcal  infection  (A.  F.). 


THE  DIAGNOSIS  OF  URETHRITIS  111 

Another  position  whicli  also  answers  consists  in  letting  the  patient  bear 
down  at  the  edge  of  a  table,  and  asking  him  to  sit  on  the  index  of  the  surgeon, 
which  has  been  passed  into  the  rectum.  It  is,  however,  much  more 
unpleasant  and  tiring. 

Certain  cases  cannot  be  massaged  successfully.  Despite  all  efforts,  and 
notwithstanding  energetic  pressure,  their  vesicles  cannot  be  emptied.  This 
condition  is  due  to  a  complete  obstruction  of  their  ducts,  and  has  to  be 
regarded  as  a  very  disagreeable  complication.  The  urine  remains  turbid 
for  a  very  long  time  in  these  cases,  and  our  means  of  treating  this  condition 
of  the  vesicles  are  very  limited. 

The  secretions  obtained  by  the  massage  are  submitted  to  a  microscopic 
examination  in  the  same  way  as  those  of  the  prostate. 

3.  Urethroscopic  Examination  of  the  Seminal  Vesicles. — The  urethro- 
scope only  allows  one  to  inspect  the  prostatic  utriculus  and  the  orifices  of 
the  ejaculatory  ducts. 

This  investigation  is  rather  difi&cult,  but  it  is  of  great  value  when  the 
ejaculatory  ducts  are  diseased.  In  health  the  utriculus  and  the  ejaculatory 
ducts  are  barely  visible,  but  this  changes  in  disease.  The  verumontanum 
bears  towards  the  seminal  vesicles  the  same  relation  as  the  orifices  of  the 
ureters  bear  towards  the  kidneys.  As  has  been  established  by  Professor 
Hurry  Fenwick,  the  meatoscopy  of  the  ureters  allows  one  to  foresee  and 
diagnose  an  affection  of  the  kidneys.  In  the  same  way,  the  aspect  of  the 
verumontanum  allows  one  to  foresee  and  to  diagnose  a  chronic  inflammation 
of  the  seminal  vesicles.  This  is  so  true  that  the  vermontanum  deserves  to 
be  called  "  the  mirror  of  the  seminal  vesicles." 

Examination  of  the  Female  Urethra. 

For  the  examination  of  the  female  urethra  the  following  methods  should 
be  used: 

1.  Cross-examination. 

2.  Inspection. 

3.  Palpation. 

4.  Examination  of  the  urine. 

5.  Exploratory  catheterization. 

6.  Urethroscopy. 

1.  Cross-Examination. — One  rarely  obtains  a  definite  answer  from  a 
woman  whom  one  suspects  of  having  gonorrhea,  when  one  inquires  about 
any  pain  which  she  may  have  had  during  micturition,  and  which  would 
point  to  an  acute  infection  of  her  urethra. 

Gonorrheal  urethritis  is  mild  in  women.  They  only  suffer  pain  for  a 
short  time,  and  soon  forget  all  about  it.     At  the  most  they  may  recollect 


112  GONORRHEA 

having  had  pam  for  a  day  or  so,  and,  in  the  vast  majority  of  cases,  they  only 
become  aware  of  the  inflammation  of  their  urethra  if  cystitis  supervenes. 

As  soon  as  a  woman  realizes  the  suspicions  which  are  rife  against  her, 
she  becomes  indignant  and  protests.  She  is  certain  that  there  is  nothing 
wrong  with  her,  and  has  usually  been  examined  recently  by  her  doctor,  who 
was  unable  to  detect  any  disease.  Some  even  produce  genuine  certificates 
to  that  effect. 

One  has  to  admit  that  in  most  cases  the  women  are  perfectly  sincere. 
Absence  of  morbid  symptoms  and  normal  appearances  are  perfectly  com- 
patible with  infectiousness.  This  condition,  which  has  been  termed  "  latent 
gonococcismus,"  may  last  not  only  for  months,  but  even  for  years,  as  Gruiard^ 
has  pointed  out.  This  author  has  published  a  series  of  typical  cases  in 
which  acute  gonorrhea  was  contracted  from  women  who  seemed  to  be  in 
perfect  health.  In  all  these  cases  the  intercourses  were  frequent,  the  parties 
were  true  to  each  other,  and  the  men  developed  gonorrhea  after  having  been 
with  these  women  for  months. 

It  is  therefore  highly  desirable  to  trace  these  cases  of  latent  gonorrhea. 
The  usual  naked-eye  examination  is  quite  insufficient,  even  if  one  uses  a 
speculum,  and  combines  it  with  a  digital  exploration.  All  investigations 
without  a  microscope  are  regrettable,  not  only  for  the  sake  of  the  reputation 
of  the  medical  man  who  considers  himself  beyond  the  need  of  that  instru- 
ment, but  also  inasmuch  as  the  security  of  their  patients  is  concerned. 

The  chief  centres  in  which  gonococci  are  found  in  woman  are  the  urethra, 
the  glands  of  Bartholin,  the  vagina,  the  cervix,  the  uterus  and  its  appendages. 

2.  Inspection. — The  meatus  of  the  female  urethra  should  be  inspected 
with  great  care.  Many  women  have  material  interest  to  prove  that  they  are 
free  from  infective  lesions,  and  have  become  past-masters  in  the  art  of 
concealing  their  ailments.  The  prostitutes  know  very  well  that  it  is  to  their 
advantage  to  cleanse  their  urethra  by  making  water  before  they  are  medically 
examined,  and  some  of  them  even  go  so  far  as  to  clean  and  dry  their  urinary 
meatus  by  means  of  a  piece  of  blotting-paper,  which  they  roll  up  until  it 
is  sufficiently  pointed  to  enter  the  meatus.  Others  resort  to  copious  vaginal 
douching  before  the  medical  examination  takes  place,  and  thus  manage 
to  conceal  their  urethral  infection.  They  often  defy  by  these  tactics  even 
the  most  thorough  and  careful  examinations. 

Some  of  our  readers  will  remember  Gosselin's  famous  case.  After  having 
been  misled  for  some  time  by  a  certain  lady,  he  decided  to  pay  her  a  surprise 
visit.  He  appeared  at  her  residence  at  6  a.m.  without  warning,  and  thus 
prevented  her  from  taking  her  usual  precautions.  He  then  demonstrated 
on  the  spot,  in  the  presence  of  her  unfortunate  sweetheart,  that  she  was 
suffering  from  gonorrhea. 

^  Guiard,  Ass.  Franq.  d'Urologie,  1902,  p.  255. 


THE  DIAGNOSIS  OF  URETHRITIS 


113 


It  is  therefore  advisable  to  keep  a  woman  under  observation  for  several 
hours,  or  at  any  rate  to  make  certain  that  she  has  neither  emptied  her 
bladder  nor  used  a  douche  for  hours,  before  one  examines  her.  This  is 
the  only  way  to  assure  a  satisfactory  examination,  and  it  is  easy  to  control 
if  she  is  in  a  suitable  condition ;  for  one  has  only  to  see  if  the  quantity  of 
urine  passed  by  the  patient,  after  one  has  inspected  her  meatus,  is  suflScient. 

Verchere^  has  dwelt  upon  the  difl&culty  of  tracing  gonorrhea  in  registered 
(licensed)  prostitutes.  "  She  must  be  taken  unawares,  and  must  be  watched. 
She  should  not  be  left  alone  for  a  minute.     No  licensed  prostitute  is  ever 


Fig.  53.— ExAivnNATioi^  of  the  Female  Urethra. 


arrested  for  having  chronic  gonorrhea.  Only  a  few  novices  who  are  not  yet 
registered  are  caught,  because  they  have  not  yet  learnt  the  tricks  whichfall 
the  old  stagers  know." 

Of  fifteen  consecutive  prostitutes  who  had  been  discharged  by  the 
Dispensary,  he  found  eleven  to  be  suffering  from  gonorrhea.  In  every  case 
the  disease  had  been  overlooked,  or  rendered  unrecognizable  by  the'measures 
which  these  women  adopted  before  they  were  examined.  They  all  resort 
to  special  tactics,  such  as  drying  the  meatus  with  blotting-paper  or  swabbing 
the  vagina  dry  with  cotton-wool,  and  thus  defy  the  most  careful  search, 
1  Verchdre,  La  Blennorragie  chez  la  Femme,  vol.  i.,  1894,  Paris  (Rueff). 


114  GONOKRHEA 

apart  from  the  fact  that  some  have  so  slight  lesions  that  there  is  nothing 

to  see.     As  the  disease  may  be  latent,  the  presence  of  the  gonococcus  is  the 

only  criterion  upon  which  reliance  can  be  placed. 

Unfortunately,  this  examination  is  somewhat  tedious,  especially  if  one 

makes  several  slides.     One  places  the  woman  in  the  speculum  position, 

separates  the  labia  majora  and  minora,  and  inspects  the  orifice  of  the  urethra. 

If  a  bead  of  pus  is  visible  at  the  meatus,  one  collects  it  carefully,  and  examines 

it  under  the  microscope. 

If  the  mucous  membrane  is  red,  injElamed,  and    edematous,  an  acute 

inflammation   of   the  urethra   is   probable.     Sometimes   a   small  reddish 

swelling  is  present  at  the  meatus,  which  is  fixed  to  one  of  the  walls  of  the 

urethra:  this  is  a  polypus  or  a  granuloma,  which  in  very  many  cases  owes 

its  origin  to  a  chronic  inflammation  of  the  urethral  glands.     Or  the  mucosa 

may  show  a  certain  degree  of  prolapse,  in  which  case  one  has  to  investigate 

further  if  one  is  dealing  with  a  tumour  of 

__^^^__— ^/^i  the  urethra  or  with  a  simple  urethrocele. 

terr  ."^.^:.^Sf^Sait    ,1  In  certain  cases  the  examination  of  the 

^4^^  meatus  is  greatly  assisted  by  the  use  of  a 

N^^J  small  speculum  (Fig.  54).     The  lips  of  the 

\  \^*V  meatus  are  thus  separated,  and  interesting 

\  r  \v\        details  may  become  visible,  such  as  the 

^  \\j\     exact  place  of  insertion  of  a  polypus,  etc. 

Wj)  ^       In  most  cases,  however,  the  speculum  is 

^      ^,     c,  o  less  satisfactory  than  the  urethroscope, 

Fig.  54,— Small  Speculum  fob  pi       n   i  r        -i 

THE  Female  Urethra.  which   therefore  should  be  preferred   as 

a  rule. 

The  inspection  of  the  meatus  should  include  the  entire  zone  around  it. 
The  meatus  of  some  women  is  surrounded  by  small  depressions,  glandular 
crypts,  which  are  prone  to  gonococcal  infection.  Several  of  these  recesses 
may  undergo  partial  obliteration,  and  thus  form  encysted  abscesses  which 
are  liable  to  perpetuate  the  gonorrhea  indefinitely.  These  depressions 
should  not  only  be  looked  for;  they  should  also  be  carefully  explored  indi- 
vidually by  means  of  a  stylet,  in  order  to  ascertain  that  none  of  them  contain 
gonococci. 

In  woman,  whose  vulva  is,  so  to  say,  nothing  but  a  mass  of  glands, 
suitable  hiding-places  for  the  gonococcus  abound. 

As  Guiard  has  pointed  out,  superficial  scrapings  should  be  taken  from 
these  crypts  and  examined  microscopically.  It  is  not  sufficient  to  collect 
the  purulent  secretions  on  a  platinum  loop  which  has  been  passed  through 
the  flame.  It  is,  of  course,  essential  that  these  researches  be  carried  out 
only  if  one  is  certain  that  the  patient  has  not  douched  herself  four  to  five 
hours  previously,  and  that  she  has  not  made  water. 


THE  DIAGNOSIS  OF  URETHRITIS  115 

The  examination  of  Bartholin's  glands  should  never  be  neglected. 
Chronic  inflammation  of  these  glands  is  nearly  always  painless,  and  usually 
escapes  the  notice  of  the  patient. 

By  introducing  a  finger  into  the  vagina,  and  by  pressing  simultaneously 
with  another  finger  from  the  outside  on  the  labium  majus,  a  small  tumour, 
varying  in  size  from  a  small  cherry  to  a  plum,  is  felt. 

If  the  inflammation  is  more  recent,  a  few  drops  of  pus  may  issue  from 
the  duct  of  the  gland  when  one  presses  on  the  swelling.  This  pus  contains 
gonococci  in  nearly  every  instance. 

Besides  Bartholin's  glands,  which  are  so  commonly  infected,  one  occasion- 
ally finds  around  the  meatus  little  elevations  which  are  traversed  by  minute 
ducts.     The  latter  are  often  infected,  and  are  very  difficult  to  cure. 

Sometimes  congenital  abnormalities  are  present,  such  as  the  para- 
urethra,^  accessory  ducts  due  to  a  developmental  error.  One  of  Jullien's 
female  patients  had  a  pervious  duct  of  Gartner,  which  was  embedded  in  the 
lateral  wall  of  her  vagina,  and  opened  at  the  vulva.  During  her  attack  of 
gonorrhea  this  duct  became  infected. 

Lastly,  it  is  absolutely  necessary  to  pass  a  speculum  into  the  vagina, 
and  to  examine  the  secretions  of  the  cervix,  which  should  be  collected  with 
a  platinum  loop  and  examined  microscopically. 

The  cases  in  which  the  gonococcus  is  found  at  the  first  examination  are 
not  common.  It  is  therefore  advisable,  in  order  to  be  sure  of  a  reliable 
result,  to  proceed  in  two  stages:  A  swab  of  cotton-wool  is  placed  on  the 
cervix,  and  left  there  for  twenty-four  hours.  One  then  withdraws  it,  and 
examines  the  secretions  on  it  for  gonococci. 

3.  Palpation. — Palpation  should  accompany  inspection.  In  this  way 
very  accurate  information  can  be  obtained  in  cases  of  urethral  inflam- 
mation. 

The  palpation  is  carried  out  by  means  of  the  left  index-finger,  which  is 
lubricated  with  vaseline,  and  introduced  into  the  vagina  in  such  a  way 
that  its  palmar  surface  is  in  intimate  contact  with  the  under-surface  of  the 
urethra.  The  index  is  pushed  as  far  as  the  anterior  fornix  of  the  vagina, 
and  is  then  gently  withdrawn  along  the  anterior  vaginal  wall.  The  finger 
should  press  firmly  against  the  latter. 

In  this  way  the  urethra  is  squeezed  out,  and  often  a  bead  of  pus  can  be 
obtained  from  the  meatus.  This  discharge  originates  from  the  urethral 
mucous  membrane,  or  from  the  glands  connected  with  it,  and  should  be 
microscoped. 

In  some  cases  this  examination  can  be  completed  with  advantage  by 
moving  a  blunt  curette  gently  to  and  fro  in  the  urethra.     The  secretions  are 
collected  with  greater  precision  in  this  way  than  with  a  platinum  loop. 
1  Jayle,  Revue  de  Oynecologie,  August,  1909. 


116  GONORRHEA 

4.  Examination  of  the  Urine. — This  investigation  should  always  be 
made  after  the  first  three  examinations  have  been  concluded.  Carried  out 
in  this  order,  it  does  not  interfere  with  them,  and,  moreover,  it  allows  one 
to  verify  if  the  woman  is  in  a  suitable  condition  to  be  examined.  The  more 
urine  she  passes,  the  longer  she  has  been  without  cleansing  her  urethra. 

The  urine  is  tested  in  the  same  way  as  in  the  case  of  man ;  it  is  passed  by 
normal  micturition,  and  collected  in  four  glasses.  When  a  simple  urethritis 
is  present,  the  first  glass  is  turbid,  whilst  the  second  one  is  clear.  If  the 
urethral  inflammation  is  complicated  by  cystitis,  all  the  glasses  contain 
turbid  urine. 

5.  Exploratory  Catheterization. — This  method  of  examination  is  contra- 
indicated  whenever  the  urethra  is  in  a  state  of  acute  inflammation.  As  in 
the  case  of  the  male,  it  would  cause  pain  and  be  badly  tolerated.  More- 
over, it  would  be  apt  to  give  rise  to  complications,  such  as  inflammation  of 
the  urethral  glands  and  cystitis. 

It  is  therefore  only  indicated  after  the  urine  has  become  clear,  especially 
the  specimen  contained  in  the  first  glass. 

The  intervention  itself  is  carried  out  by  means  of  an  olivary  bougie 
which  is  passed  into  the  bladder,  and  then  gently  withdrawn  towards  the 
meatus.  The  heel  of  the  olive  will  detect  any  narrowing,  or  roughness,  or 
loss  of  dilatability,  of  the  urethral  walls. 

6.  Urethroseopic  Examination. — The  urethroscopic  examination  of  the 
female  urethra  should  be  a  matter  of  routine.  It  is  the  best  means  of 
ascertaining  certain  important  details  {vide  Chapter  VIII.)  which  would  be. 
overlooked  otherwise,  or  never  be  suspected. 


CHAPTER  VIII 
URETHROSCOPY 

The  Importance  of  Urethroscopy. 

The  study  of  the  urethral  mucous  membrane  by  direct  inspection  is  termed 
"  urethroscopy,"  and  is  carried  out  by  means  of  a  special  instrument,  the 
urethroscope. 

In  order  to  obtain  a  clear  idea  of  the  value  and  of  the  importance  of 
urethroscopy,  one  has  to  realize  the  great  services  which  direct  inspection 
of  the  urethra  has  rendered  in  urethral  disease,  and  especially  in  its  most 
common  form — chronic  urethritis. 

The  Value  of  Urethroscopy  in  Chronic  Urethritis. — It  is  well  known 
nowadays  that  chronic  urethritis  is  a  localized  disease,  and  that  the  inflam- 
matory patches  which  perpetuate  it,  are  in  the  majority  of  cases  circum- 
scribed and  well  defined.  The  whole  secret  of  a  successful  treatment  con- 
sists in  the  knowledge  of  these  localizations,  of  their  different  types,  and  of 
the  way  of  healing  them. 

One  thus  understands  why  so  many  methods  and  instruments  for  explor- 
ing the  urethra  and  its  appendages  should  have  been  invented,  and  why 
they  have  been  in  use  for  a  long  time.  Amongst  these  exploratory  methods, 
endoscopy  of  the  urethra  is  of  special  importance,  both  from  a  diagnostic 
and  from  a  therapeutic  point  of  view. 

The  urethroscope  bears  the  same  relation  to  the  urethra  as  the  stethoscope 
does  to  the  heart,  the  X  rays  to  fractures,  the  laryngoscope  to  the  larynx,  and 
the  ophthalmoscope  to  the  eye.  Although  one  does  not  require  a  stethoscope 
for  a  rough  diagnosis  of  a  heart  lesion,  this  valuable  instrument  allows  one 
to  define  and  to  locate  accurately  a  cardiac  murmur.  The  clinical  symptoms 
are  sufficient  to  diagnose  a  fractured  bone,  but  the  X  rays  and  the  fluorescent 
screen  are  indispensable  in  many  cases  for  ascertaining  the  direction  of  the 
line  of  the  fracture,  and  for  selecting  the  most  suitable  and  beneficial  form 
of  treatment.  In  the  same  way  the  urethroscope  permits  us  to  tell  exactly 
in  which  portion  of  the  urethra  the  lesions  are  to  be  found. 

People  who  claim  to  have  a  scientific  mind,  should  be  reluctant  to  institute 
an  active  therapy  against  any  morbid  condition  which  is  only  incompletely 

117 


118  '  GONOREHEA 

known  to  them.     To  work  in  the  dark,  to  treat  urethral  inflammation  on  a 
purely  empirical  basis,  is  not  consistent  with  the  requirements  of  our  age. 

Under  normal  conditions  the  walls  of  the  urethra  escape  our  view,  and 
our  usual  means  of  investigation  only  allow  one  to  diagnose  the  gross  lesions. 
It  is  the  aim  of  urethroscopy  to  fill  this  gap,  to  enable  us  to  see  the  circum- 
scribed lesions  in  the  urethra,  and  to  discover  their  situation,  their  extent, 
and  their  shape.  This  diagnostic  method  fulfils  thus  the  postulate  of  rational 
surgery ;  it  enables  us  to  ascertain  de  visu  the  lesions  within  the  urethra,  to 
diagnose  them  accurately,  and  to  treat  them  accordingly. 

No  method,  except  direct  inspection  by  means  of  the  urethroscope, 
acquaints  us  with  all  the  folds  and  all  the  recesses  in  the  urethral  mucosa. 
No  method  is  more  suitable  for  determining  to  which  portion  of  the  urethra 
the  lesions  of  any  given  case  of  chronic  urethritis  belong. 

By  examining  the  urine  and  the  filaments  contained  in  it  with  the  four- 
glass  method,  a  gross  differentiation  between  lesions  of  the  anterior  urethra 
and  those  of  the  posterior  urethra  can  be  made.  But  this  method  fails  hope- 
lessly, for  instance,  when  one  is  confronted  with  the  task  of  determining  in 
which  part  of  the  anterior  urethra  the  lesions  present  are  located. 

The  anterior  urethra  is  of  considerable  length,  and  different  methods  and 
totally  different  instruments  are  required  according  to  the  part  which  is 
afiected. 

Lesions  of  Littre's  glands  in  the  penile  portion  demand  a  treatment  which 
is  quite  unsuitable  for  inflammatory  troubles  located  in  the  cul-de-sac  of  the 
bulb.  How  can  one  be  sure  of  the  seat  of  a  lesion  if  one  has  not  seen  it  ? 
Only  the  urethroscope  can  give  the  necessary  information. 
It  should  also  not  be  forgotten  that,  apart  from  its  diagnostic  value, 
this  instrument  enables  one  to  apply  an  energetic  local  treatment  to  the 
lesion  which  one  has  found  and  examined.  I  wish  to  insist  upon  the  value 
and  the  importance  of  this  mode  of  therapy.  Moreover,  is  it  not  more 
logical  to  treat  a  lesion  surgically,  under  the  control  of  the  eye,  than  to 
experiment  in  the  dark  ? 

Then,  again,  urethroscopy  allows  one  to  control  the  results  of  any 
methodical  treatment  which  has  been  carried  out.  One  can  thus,  for 
instance,  follow  step  by  step  the  improvement  obtained  during  a  course  of 
dilatations. 

In  the  case  of  hemorrhage  from  the  urethral  mucosa,  the  tear  produced 
by  excessive  dilatation  can  be  located ;  one  is  able  to  convince  oneseK,  by 
inspection,  of  the  necessity  of  allowing  an  interval  of  sufficient  duration 
between  the  various  dilatations,  and  one  can  see  that  any  attempt  to  dilate 
merely  separates  the  edges  of  the  tear  until  cicatrization  is  complete,  and 
that  the  widening  effect  upon  the  sound  part  of  the  urethral  wall  is  insignifi- 
cant in  cases  of  this  kind.     Dilatation  treatment  yields  its  best  results  when 


URETHROSCOPY  119 

it  is  carried  out  gradually  and  metkodically  under  the  control  of  the 
urethroscope.  Blind  and  haphazard  stretching  does  no  good,  and  may  do 
a  great  deal  of  harm. 

May  the  above  remarks  suflS.ce  to  show  how  ill-founded  most  of  the 
criticisms  are  which  have  been  advanced  against  urethroscopy ! 

The  argument  which  one  so  often  hears,  that  urethroscopy  tells  us 
nothing  beyond  the  information  which  the  ordinary  methods  of  investiga- 
tion yield,  is  hardly  worth  considering. 

One  has  only  to  glance  at  the  pictures  contained  in  this  book  in  order 
to  realize  how  the  urethroscope  has  lifted  the  veil  from  the  mysterious 
causes  of  certain  rebellious  urethrites,  and  of  a  vast  number  of  therapeutic 
failures. 

As  to  the  accidents  which  may  follow  upon  the  use  of  this  instrument 
(epididymitis,  cystitis,  etc.),  they  are  absolutely  avoidable  if  one's  technique 
has  reached  the  necessary  standard  {vide  Technique). 

Urethroscopy  should  never  be  made  use  of  for  the  diagnosis  of  diffuse, 
recent,  and  acute  inflammations.  It  has  its  well-defined  indications,  which 
are  set  forth  in  this  chapter.  Correctly  employed,  and  with  careful  manipu- 
lations, it  never  gives  rise  to  the  slightest  accident. 

To  resume :  The  urethroscope  should  be  accepted  nowadays  as  a  common 
instrument  for  exploring  the  urethra.  For  diagnostic  purposes  it  gives  in- 
finitely more  accurate  information  than  any  other  method  of  examination. 
For  therapeutic  purposes  it  gives  the  means  of  treating  the  lesions  with  astonish- 
ing precision  and  efficiency.  It  is  indispensable  in  the  treatment  of  chronic 
urethritis. 

Moreover,  those  who  have  practised  the  urethroscopic  method  for  some 
time,  and  have  become  familiar  with  its  technique,  finally  begin  to  wonder 
why  one  does  not  always  use  this  precious  diagnostic  and  therapeutic  method, 
which  is  so  practical  and  so  powerful. 

The  congested  patches,  the  ecchymoses,  the  gelatinous  infiltrations  of 
the  mucous  membrane,  become  visible,  and  with  proper  judgment  and  an 
up-to-date  instrumental  outfit  one  has  the  satisfaction  of  doing  truly  scientific 
and  useful  surgical  work. 

On  the  Great  Importance  of  Urethroscopy  for  making  sure  that  a  Case  of 
Gonorrhea  is  completely  cured. — It  is  unnecessary  to  dwell  upon  the  impor- 
tance of  ascertaining  whether  a  patient  has  been  completely  cured  of  his 
urethritis  or  not.  Everybody  is  aware  that  an  incorrect  answer  to  this 
question  may  lead  to  a  series  of  calamities. 

Searching  for  a  discharge  after  the  patient  has  remained  without  making 
water  for  several  hours,  and  the  examination  of  the  urine  and  of  its  filaments, 
certainly  yield  precious  information,  and  the  same  is  true  for  the  examina- 
tion of  the  prostate  by  massage  and  for  the  exploration  of  the  urethra 


120  GONOREHEA 

stretched  on  a  metal  sound.  But  even  despite  these  investigations  one  is 
often  disagreeably  surprised  by  recurrences  which  seem  inexphcable,  and 
which  would  lead  to  disastrous  consequences  should  one  have  already  given 
the  patient  one's  consent  to  marry. 

Whenever  it  is  a  question  of  marriage,  all  possible  precautions  must  be 
taken  in  order  to  safeguard  the  family,  and  the  most  important  of  these 
precautions  is  a  thorough  and  complete  examination  of  the  urethral  mucous 
membrane  by  means  of  the  urethroscope.  It  is  the  most  precise  means  of 
telling  if  the  patient  is  completely  cured,  and  on  its  result  depends  if  the 
fiance  may  be  given  the  clean  bill  of  health  which  allows  him  to  embark 
upon  matrimony  with  a  clear  conscience  and  physical  aptitude. 

Nowadays,  no  patient  should  be  told  that  he  is  completely  cured  unless  he  has 
undergone  a  satisfactory  examination  of  his  urethra  by  means  of  the  urethroscope. 

In  the  following,  several  cases  are  described  in  which  the  gonococci 
persisted  within  the  mucous  membrane  of  the  urethra  for  many  years,  and 
yet  their  presence  was  never  suspected.  Cases  of  this  kind  bring  home 
forcibly  the  necessity  of  a  urethroscopic  examination  before  the  patient 
marries. 

Professors  Oberlander  and  KoUmann  say  on  this  subject:^  "However 
benign  the  case  under  observation  may  appear,  one  should  not  satisfy  one- 
self with  a  single  examination  for  the  purpose  of  ascertaining  if  the  patient 
is  cured.  Several  examinations  are  required,  and  one  should  allow  weeks 
to  elapse  between  them,  and  not  a  few  days.  .  .  .  On  each  occasion  a 
careful  urethroscopic  examination  should  be  made.  The  patient  should 
have  held  his  water  for  five  or  six  hours,  and,  above  everything,  no  cocain 
should  be  used.  .  .  .  The  whole  passage  should  be  examined  from  one  end 
to  the  other,  and  a  complete  cure  may  be  diagnosed  if  the  canal  fulfils  the 
following  conditions : 

"  The  mucosa  must  show  normal  folds  and  a  perfect  longitudinal  stria- 
tion.  There  should  be  no  difference  in  the  colour  of  the  parts  which  were 
affected  and  of  those  which  remained  healthy.  The  epithelium  should  be 
of  an  equal  lustre  in  all  its  parts.  The  lacunae  and  Littre's  glands  should 
have  ducts  which  show  no  sign  of  irritation.  The  periglandular  infiltra- 
tions and  the  cicatrices  of  the  destroyed  glands  should  not  project  beyond 
the  general  level  of  the  mucosa.  They  should  be  covered,  like  the  rest,  by 
a  healthy  epithelium. 

"The  other  cicatrices  which  may  have  formed,  and  which  are  sub- 
epithelial, must  have  become  invisible,  and  should  be  covered  by  an  epi- 
thelial surface  which  is  normal  in  its  appearance  and  in  its  lustre." 

There  can  be  no  doubt  that  one  should  take  all  possible  precautions, 
when  one  has  to  assume  the  responsibility  of  giving  one's  consent  to  a 
^  Oberlander  and  Kollmann,  Die  Chronische  Gonorrhoe,  Leipzig,  1901,  p.  168. 


URETHROSCOPY  121 

marriage,  and  one  cannot  but  endorse  the  principles  laid  down  by  Pro- 
fessors Oberlander  and  Kollmann.  However,  tbere  certainly  are  cases  in 
which  there  is  no  hope  of  accomplishing  a  restitutio  ad  integrum.  Instances 
in  point  are  strictures. 

Therefore  :  one  must  be  certain  that  all  definitely  infectious  organisms, 
such  as  the  gonococcus  and  the  adventitious  bacteria,  have  disappeared, 
and  with  them  all  possibility  of  contamination,  and  repeated  thorough 
urethroscopic  examinations  must  have  shown  that  there  is  no  focus  left 
which  could  conceal  these  organisms.  Under  these  conditions  one  is  entitled 
to  give  one's  consent  to  the  marriage. 

The  History  of  Urethroscopy. 

Urethroscopy  is  by  no  means  a  new  science;  its  beginnings  date  about 
one  hundred  years  back. 

A  few  unsuccessful  attempts  at  obtaining  a  direct  view  of  the  urethra 
were  made  in  1805  by  Bozzini  of  Frankfort,^  and  by  Segalas  in  1826.^  The 
first  serviceable  urethroscope,  however,  was  devised  in  France  by  Desor- 
meaux  in  1853.^    His  invention  marks  the  beginning  of  urethroscopy. 

Since  then,  much  work  has  been  done  on  this  subject,  and  in  connection 
with  it  we  may  mention  the  names  of  Hacken'*  (1862),  Cruise^  (1865), 
Andrews^  (1867),  Furstenheim'  (1870),  and  Stein^  (1874). 

A  great  number  of  different  instruments  have  been  built;  and  although 
the  list  is  large  enough  as  it  is,  it  is  not  yet  closed,  and  new  urethroscopes 
are  being  constantly  put  on  the  market. 

They,  however,  all  belong  to  either  one  of  the  following  groups : 

1.  Urethroscopes  with  external  illumination — i.e.,  instruments  in  which 
the  source  of  light  is  outside  the  urethroscopic  tube. 

2.  Urethroscopes  with  internal  illumination — i.e.,  those  which  carry 
their  lamp  inside  the  endoscopic  tube. 

^  Bozzini,  Der  LichUeiter  oder  Beschreibung  einer  einfachen  Vorrichtung  und  ihrer 
Anwendung  zur  Erleuchtung  innerer  Hohlen  und  Zwischenriiume  des  lebenden  animal- 
ischen  Korpers,  Weimar,  1807. 

2  Segalas,  Compte  Rendu  de  VAcad.  des  Sciences,  1826;  Traite  des  Retentions  d' Urine, 
Paris,  1828. 

3  Desormeaux,  Bull,  de  VAcad.  de  Mid.,  1853;  De  l' Endoscope  et  de  ses  Applications 
au  Diagnostic  et  au  Traitement  des  Maladies  de  VUretre  et  de  la  Vessie,  1865. 

*  Hacken,  "  Dilatatorium  Urethrae  zur  Urethroscopie,"  Wien.  Med.  Woch.,  1862, 
No.  12. 

^  Cruise,  "  The  Utility  of  the  Endoscope,"  Dublin  Quart.  Journ.  of  Med.  Sci.,  May, 
1865. 

^  Andrews,  "The  Urethra  viewed  by  a  Magnesium  Light,"  Med.  Record,  vol.  ii., 
p.  107,  1867. 

■^  Fiirstenheim,  Berl.  Klin.  Woch.,  1870,  Nos.  3  and  4 ;  Oesterreich.  Zeits.f.  Prakt.  HeilL, 
1870,  No.  25. 

8  Stem,  "  Das  Photoendoscop.,"  Berl.  Klin.  Woch.,  1874,  No.  3. 


122 


GONOEKHEA 


1.  Ueetheoscopes  with  External  Illumination. 

This  group  comprises  two  distinct  types.  In  the  former  the  light  is 
fixed  to  the  tube  of  the  urethroscope,  whilst  in  the  latter  the  illumination 
is  independent  of  the  tube. 

1.  Urethroscopes  with  External  Illumination  attached  to  the  Urethro- 
SCOpic  Tube. — This  was  the  first  type  to  be  invented,  and  dates  from  Desor- 
meaux,  the  father  of  urethroscopy.  His  instrument  consisted  in  its  essential 
parts  of  ordinary  urethroscopic  tubes  to  which  an  artificial  light  had  been 
added.  The  accompanying  figure  dispenses  with  a  long  description.  In  the 
first  model  the  light  was  derived  from  an  oil  lamp,  and  in  the  later  ones  a 
petrol  lamp  was  substituted.     This  illumination,  however,  proved  inade- 


FiG.  55. — Desokmeaux's  Urethkoscope. 


quate,  and  it  was  only  after  an  electric  light  had  been  adapted  that  the 
instrument  was  able  to  fulfil  its  role.  It  was  Horteloup  who  thus  greatly 
improved  Desormeaux's  instrument. 

Other  instruments  which  belong  to  the  same  type  are — 
(1)  Leiter's  pan-electroscope.  This  instrument  consists  of  tubes  of 
different  width  and  length,  corresponding  to  Nos.  18  and  20.  Each  tube 
has  its  metal  pilot  by  means  of  which  it  is  introduced  into  the  urethra. 
The  illumination  is  derived  from  an  electric  lamp,  B,  carried  in  a  haK- 
cylinder,  of  which  the  upper  part  is  missing.  The  light  from  the  lamp  is 
reflected  by  a  mirror,  D,  into  the  urethroscopic  tube  A.  By  means  of 
the  lens  C,  which  can  be  replaced  by  other  sizes  to  suit  the  observer's 
eye,  the  image  seen  at  the  fundus  of  the  tube  is  magnified. 

Heitz-Boyer  has  taken  this  instrument  up,  and  had  it  shown  at  the 
Society  of  Surgery  in  Paris. ^     The  only  improvement  worth  mentioning 

1  Bull,  de  la  Soc.  de  Chirurgie,  January  4,  1911,  p.  38. 


UEBTHROSCOPY 


123 


Fig.  56. — Hortelotjp's  Ubetheoscope. 
The  cylinder  which,  contains  the  lamp  is  closed.     A  is  a  concave  mirror  ;^C  is  a  powerful 
lens  which  intensifies  the  light,  which  is  reflected  by  the  inclined  mirror  F  into  the 
urethroscopic  tube.     This  tube  is  fitted  on  in  E.     D  is  the  eyepiece,  which  contains 
a  combination  of  lenses. 


Fig.  57. — Leiter's  Pan-Elegtkoscope. 

The  upper  part  is  open.     The  light  is  reflected  by  the  mirror  D  into  the  speculum  A. 
The  images  are  magnified  by  a  lens,  C. 


124 


GONOKKHEA 


consisted  in  the  adoption  of  the  illuminator  which  Briining  uses  for  his 
esophagoscope.  The  objections  to  all  instruments  with  external  illumina- 
tion (see  p.  129)  naturally  hold  good  in  this  case. 

Already  Horteloup,  who  used  Leiter's  pan-electroscope  for  a  time,  found 
it  inconvenient,  and  discarded  it.  He  returned  to  Desormeaux's  instru- 
ment, which  he  fitted  with  an  electric  lamp.^ 

(2)  Schutze's  diaphotoscope. 


Fig.  58. — Schutze's  Diaphotoscope. 
(3)  Nyrops's  electro-urethroscope. 


Fig.  59. — Nykops's  Electro-Urethroscope, 
1  Horteloup,  Ureirite  Chronique,  Paris  (Masson),  1892,  p., 43. 


UKETHROSCOPY 


125 


(4)  Lang's  urethroscope. 


Fig.  60. — Lang's  Urethroscope. 
(5)  Otis's  urettroscope. 


Fig.  61. — Otis's  Urethroscope. 


(6)  Casper's  electroscope  (see  p.  126), 

(7)  Von  Antal's  aero-urethroscope  (see  p.  127)  was  a  distinct  advance  on 
the  older  instruments.  It  was  designed  with  the  intention  of  separating  and 
unfolding  the  walls  of  the  urethra,  in  order  to  obtain  a  more  thorough  view. 
The  outer  end  of  the  endoscopic  tube  was  closed  by  a  glass  window,  and 
fitted  with  a  tap  through  which  air  could  be  blown  into  it  by  means  of 
bellows.  During  the  urethroscopic  examination,  the  window  prevented  the 
air  from  escaping  without  interfering  with  the  view.    An  assistant  com- 


126 


GONOKKHEA 


pressed  the  far  end  of  the  urethra  by  pressing  on  it  "per  rectum,  thus  ob- 
Hterating  it  either  at  the  membranous  portion  or  at  the  perineum.  This 
technique  separated  the  walls  of  the  urethra  owing  to  the  pressure  of  the 
air,  and  made  it  possible  to  examine  their  surface  to  an  extent  of  a  couple 
of  centimetres. 

(8)  This  instrument  has  been  modified  by  Professor  Hurry  Fenwick  of 
London  (Fig.  64). 

2.  Urethroscopes  with  External  and  Independent  lUummation. — This 
method  is  due  to  Griinfeld  of  Vienna,  who  in  1881  introduced  a  hollow 
tube  into  a  urethra,  and  then  projected  luminous  rays  into  this  tube  from 
a  reflector.  His  reflector  was  pierced,  and  through  this  opening  he  observed 
the  urethral  mucous  membrane.  As  sources  of  light,  he  made  use  of  day- 
light and  artificial  light  (electric,  gas,  petrol).     The  reflector  was  fitted  with 


Fig.  62. — Casper's  Electroscope. 


a  handle,  and  held  with  one  hand.  In  the  later  models  a  frontal  mirror 
was  used,  which  was  subsequently  improved  by  Clar  (Fig.  65). 

Griinfeld  used  straight  urethroscopic  tubes  as  well  as  curved  ones  (Fig.  66) . 
He  also  devised  a  straight  tube  which  was  fitted  with  a  side-window  and  a 
reflecting  mirror  (FensterspiegelendosJcop).  The  distal  end  of  these  tubes 
carried  a  glass  window  about  1-5  to  2  centimetres  long,  and  was  closed  by  a 
metal  stopper,  to  which  a  small  mirror  was  fixed  at  an  angle  of  45  degrees. 
This  terminal  mirror  reflected  the  light  on  to  the  urethral  wall  through  the 
window,  and  thus  rendered  it  visible  (Fig.  67). 

The  urethroscopic  tubes  have  since  been  modified  by  many  authors. 
Posner,  for  instance,  advised  to  cover  the  inside  of  the  tubes  with  a  black 
varnish,  in  order  to  prevent  the  operator  from  being  dazzled  by  the  light 


URETHROSCOPY 


127 


reflected  from  the  walls  of  the  tube.  Others  recommended  tubes  made  of 
the  same  material  as  elastic  catheters,  and  others,  again,  wished  to  have 
vulcanite  ones. 

Auspitz  invented,  for  the  purpose  of  obtaining  a  larger  visual  field,  an 
instrument  with  two  movable  valves,  which  were  opened  when  the  instru- 
ment was  in  the  urethra.     In  this  way,  a  larger  surface  of  the  mucous  mem- 


FiG.  63. — VoN  Antal's  Aero -Urethroscope. 


brane  was  brought  into  view  without  stretching  the  meatus.     This  arrange- 
ment has  also  been  adopted  by  Oberlander  and  by  Horteloup  (Fig.  68). 

Then  Janet  advocated  a  double  endoscope,  which  consisted  of  two  tubes 
one  inside  the  other.  The  inner,  smaller  one  is  fenestrated,  and  gives  a 
view  of  the  neck  of  the  bladder.  The  outer  one  is  an  ordinary  urethroscopic 
tube  which  is  open  at  both  ends,  and  is  handled  in  the  usual  way. 


128 


GONOKEHEA 


Recently  Professor  Kollmann  and  Dr.  Wiehe  have  designed  tubes  which 
widen  out  at  their  distal  end  by  the  manipulation  of  a  screw  attached  to 


Fig.  64. — Fbnwick's  Aero-Ubethboscope. 

their  proximal  end.  The  arrangement  is  very  ingenious,  but  most  unsatis- 
factory, the  enlargement  of  the  visual  field  obtained  being  insignificant,  and 
in  no  way  proportionate  to  the  intricacy  of  the  device  (Fig.  69). 


Fig.  65. — Gear's  Photophobe. 


Advantages  and  Drawbacks  of  Urethroscopes  with  External  Illumination. 

— ^The  chief  advantage   of  all  urethroscopes  with    external    illumination 
is  the  ease  with  which  intra-urethral  manipulations  can  be  carried  out. 


URETHROSCOPY 


129 


Swabs  and  their  holders  and  other  instruments  can  be  moved  about  freely 
in  them,  and  there  is  no  risk  of  soiling  or  damaging  the  source  of  light. 

In  addition,  their  field  of  vision  is  slightly  wider  than  that  of  the  instru- 
ments with  internal  illumination,  because  the  lamps  always  take  up  some 
room  in  the  latter. 

They  have,  however,  a  series  of  defects  which  are  not  fully  compensate  d 
by  these  advantages. 

First  of  all,  they  do  not  give  a  clear  and  easily  visible  image.  However 
strong  the  light  may  be,  it  is  always  too  weak  at  the  very  spot  at  which 


Fig.  66. — Ordinary  Urethroscopic  Tube  and  its   Pilot. 

it  should  be  strongest — namely,  at  the  far  end  of  the  tube.  If  one  wishes 
to  inspect  an  object  closely,  one  brings  the  light  as  near  as  possible  to  it, 
and  the  same  reasoning  holds  good  for  the  inspection  of  the  urethra.  For 
this  reason,  instruments  with  internal  illumination  are  always  to  be  pre- 
ferred.^ 

I  have  made  a  series  of  comparative  experiments  in  order  to  satisfy 
myseK  of  the  truth  of  this  statement,  and  they  have  decided  in  favour  of 


Fig.  67. — Grunpbld's  Fenestrated  Tube  with  Reflecting  Mirror. 


internal  illumination.  The  nearer  the  light  is  to  the  object  which  one 
desires  to  inspect,  the  better  are  the  conditions  for  obtaining  a  good  image, 
and  vice  versa.  Even  a  powerful  lighthouse  throws  less  light  on  a  very 
distant  surface  than  a  small  electric  lamp  in  its  immediate  neighbourhood. 
Then,  again,  all  the  instruments  with  independent  illumination,  such  as 
Clar's  photophore,  require  great  experience  and  manipulative  skill  for 
directing  the  rays  into  the  urethroscopic  tubes.     Moreover,  they  condemn 

1  Luys,  Bull,  de  la  Soc.  de  Vlnternat,  February  22,  1905,  p.  ;23. 


130 


GONOEEHEA 


the  surgeon  to  an  attitude  of  rigidity  and  immobility,  as  the  slightest  move- 
ment upsets  the  whole  optic  system.     This  is  a  great  inconvenience. 

When  the  lamp  is  attached  to  the  proximal  end  of  the  urethroscopic 
tube,  this  opening  is  hidden,  and  one  has  to  look  through  a  hole  in  the 


Fiu.  68. — HoRTELOUP's  Bivalve  Speculum. 


mirror.  Or  the  handle  of  the  instrument  is  fitted  with  an  elaborate  system 
of  lenses  and  mirrors,  which  render  it  very  clumsy  and  heavy— uncomfort- 
able for  the  patient,  and  difficult  to  handle  as  far  as  the  surgeon  is  con- 
cerned. 


Tube  of  Kollmann-Wiehe. 


Lastly,  it  is  impossible  to  use  any  straight  instruments.  One  requires  a 
special  outfit  of  coude  instruments — another  unnecessary  complication. 

For  all  these  reasons,  it  does  not  seem  as  if  the  urethroscopes  with 
external  illumination  could  ever  become  practical  instruments  which  can 
be  handled  with  ease. 


URETHROSCOPY 


131 


2.  Urethroscopes  with  Internal  Illumination. 

Nitze,  in  1879,  was  the  first  to  realize  the  advisability  of  placing  the  light 
at  the  far  end  of  the  urethroscopic  tube,  close  to  the  surface  under  examina- 
tion.^ This  is  the  best  arrangement,  for  "  if  one  wishes  to  light  up  a  room, 
one  takes  a  lamp  along."  ^ 

Nitze's  instrument  consisted  of  an  ordinary  urethroscopic  tube,  which 
contained  in  its  walls  three  small  secondary  channels.     One  of  these  carried 


Fig.  70. — ^Nitze's  Urethroscope. 

an  electric  wire  which  led  to  the  illuminator,  an  incandescent  platinum 
wire  placed  at  the  far  end.  The  other  two  channels  formed  part  of  a  water 
circulation  system,  A  constant  flow  of  cold  water  through  the  instrument 
was  necessary,  owing  to  the  intense  heat  of  the  illuminator.  This  primitive 
instrument  was  not  of  much  service.  Its  incandescent  part  took  up  too 
much  room,  and  thus  rendered  the  field  of  vision  very  small. 

Nitze's  ideas  were  taken  up  by  Leiter  and  by  Oberlander,  who  devised 
an  instrument  which  outclassed  all  others  at  the  time. 


Fig.  71. — Oberlander' s  Urethroscope. 


His  instrument  gave  a  very  good  view  of  the  urethral  mucous  membrane, 
but  it  had  two  drawbacks — firstly,  it  required  a  circulation  of  cold  water 
to  cool  the  incandescent  wire;  and,  secondly,  it  compelled  the  operator  to 

1  Nitze,  "  Eine  Neue  Beleuclitungs  und  Untersuchungsmetliode  fur  die  Harnrohre," 
Wien.  Med.  Woch.,  1879,  No.  24. 

2  Nitze,  Lehrbuch  der  Kystoskopie  (2nd  edit.,  1907,  p.  8). 


132  GONORRHEA 

withdraw  the  light  every  time  he  wished  to  swab  the  urethral  mucous 
membrane. 

Valentine  of  New  York  remedied  these  defects  by  replacing  the  incan- 
descent wire  by  a  tiny  electric  lamp  mounted  on  a  long  slender  metal  tube 
of  sufficient  length  to  reach  the  margin  of  the  far  end  of  the  urethroscopic 


^^B 


Fig.  72. — Valentine's  Urethroscope. 

tube.    The  holder  of  the  lamp  is  inserted  into  a  handle,  which  is  provided 
with  a  switch  for  the  electric  current. 

Apart  from  this  considerable  improvement,  Valentine's  instrument  is 
practically  the  same  as  Oberlander's.  Both  instruments  have  tubes  and 
pilots  of  the  same  pattern  (Fig.  74).^ 


Fig.  73. — Lamp  of  Valentine's  Urethroscope. 

Professor  KoUmann  has  adapted  this  instrument  to  the  requirements  of 
urethro-photography,  and  has  obtained  photos  of  the  urethral  mucous 
membrane  in  this  way.^ 

Kollmann  has  also,  assisted  by  Dr.  Wiehe,  enlarged  the  visual  field  of 
his  apparatus  by  fitting  it  with  a  movable  optical  portion.  The  latter  is 
attached  to  the  lamp-holder,  and  introduced  at  the  same  time  (Fig.  77). 


Fig.  74. — Urethroscopic  Tube  and  Pilot.     (Oberlander-KoUmann.) 

Dr.  Wasserthal  of  Karlsbad  converted  Valentine's  urethroscope  into  an 
aero-urethroscope,  based  on  the  same  principle  as  Von  Antal's;  and  Dr. 

1  Oberlander  and  Kollmann,  Die  Chronische  Gonorrhoe  der  Mannlichen  Harnrohre, 
Leipzig,  1910,  p.  64. 

2  KoUmann,  "Die  Photographie  des  Harnrohreinnern,"  Centralblattf,  n.  Erankheit. 
d.  Ham.  u.  Sexualorg.,  1891,  vol.  ii.,  p.  227,  No.  391. 


URETHROSCOPY 


133 


Gordon  of  Vancouver  has  recently  devised  an  instrument  which  is   very 
similar.^ 

Dr.  R.  Kaufmann  added  a  telescope  to  the  handle  of  Valentine's  instru- 
ment, which  thus  becomes  very  heavy  and  clumsy,  and  difficult  to  use. 


Fig.  75. — Valeisttine's  Complete  Urethkoscopic  Outfit. 

Valentine's  original  instrument  was  defective  in  several  ways:  (1)  The 
exchanging  of  the  lamps  was  a  difficult  and  tedious  matter,  when  they  had 
to  be  replaced  owing  to  breakage  or  to  fusing  of  the  incandescent  wire. 


Fig.  76. — Kollmann's  Photographic  Urethroscope. 


(2)  The  lamp  itself  was  so  delicate  that  a  drop  of  fluid,  which  happened  to 
enter  its  metal  socket,  was  often  sufficient  to  set  up  a  short  circuit  and  to 
extinguish  the  Hght.     (3)  There  was  no  device  which  enlarged  the  images. 

1  The  Canadian  Medical  Assoc.  Journ.,  December,  1911. 


134 


GONOEEHEA 


Lesions  which  were  within  the  field  of  the  instrument  were  thus  easily  over- 
looked. (4)  The  small  lamp  and  its  holder  took  up  a  considerable  portion 
of  the  lumen  of  the  tube,  and  thus  reduced  the  field  of  vision  considerably. 


Fig.  77. — Handle  of  the  Kollmann-Wiehe  Urethroscope,  with  its  Lamp 
AND  ITS  Optical  Portion. 

I  have  introduced  a  series  of  important  modifications  in  order  to  remedy 
these  defects.  The  first  improvements  were  presented  at  the  meeting  of 
the  Societe  de  Chirurgie  in  Paris  on  December  24,  1902,  and  were  subse- 
quently brought  to  the  notice  of  the  Academic  de  Medecine  by  my  former 
teacher,  Professor  Le  Dentu.^ 


Fig.  78. — Wasserthal's  Aero-Urethroscope. 


1.  I  have  firstly  added  a  movable  magnifying-glass  to  the  handle.  The 
focal  length  of  the  lens  corresponds  exactly  to  the  length  of  the  urethroscopic 
tube.    The  lesions  observed  in  the  urethra  are  thus  magnified,  and  cannot 

1  Le  Dentu,  Bull,  de  VAcad.  de  Med.,  July  4,  1905. 


UKETHROSCOPY  135 

be  overlooked.  The  presence  of  a  magnifying-glass  is  a  great  advantage, 
and  it  is,  to  say  the  least,  strange  that  some  should  refuse  to  use  it.  The 
urethroscope  is,  in  the  first  place,  an  instrument  for  diagnosis,  and  as  the 
lens  allows  one  to  see  details  which  are  invisible  to  the  naked  eye,  it  is  indis- 
pensable. 

In  my  instrument  the  lens  is  movable,  and  can  be  easily  exchanged 
for  any  other  one.  The  individual  surgeon  can  therefore  always  have 
the  lens  fitted  which  suits  his  eyes  best,  whether  his  sight  be  normal 
or  not. 

2.  The  socket  which  carries  the  lamp  has  been  improved.  The  space 
between  the  metal  cup  and  the  bulb  of  the  lamp  has  been  filled  with  an 
insulating  mass.  Short-circuiting  is  thus  obviated,  should  any  moisture 
reach  the  lamp  and  its  holder. 

3.  The  lamps  can  be  exchanged  with  the  greatest  ease  and  rapidity. 


<Si 


Fig.  79. — Handle  of  Kaufmann's  Urethroscope,  with  its  Telescope. 

4.  The  various  lamps  are  mounted  on  holders  of  different  lengths  to 
match  the  different  urethroscopic  tubes  for  the  anterior  and  for  the  posterior 
urethra. 

5.  Every  tube  has  a  longitudinal  groove  which  carries  and  conceals  the 
lamp  and  its  holder. 

Amongst  the  most  interesting  publications  on  urethroscopy,  those  of 
Keersmaecker  and  Verhoogen,^  Clado,^  Fenwick,^  Kollmann,^  Valentine,^ 
Azevedo  Albuquerque,^  Frank  (of  Berlin),  Gouvea  (of  Rio  de  Janeiro), 

^  Keersmaecker  et  Verhoogen,  Uretrites  Chroniques  d'Origine  Oonococcique,  Bruxelles, 
1898. 

2  Clado,  Traite  d' Hysteroscopie,  1898. 

3  Fenwick,  Obscure  Disease  of  the  Urethra,  London,  1902. 

4  KoUmann,  "  Die  Photographic  des  Harnrohreinnern,"  Centralhldttfur  die  Physiol, 
und  Path,  der  Harn  und  Sexualorgan,  1891. 

5  Valentine,  The  Irrigation  Treatment  of  Gonorrhea,  New  York  (William  Wood 
and  Co.),  1900,  p.  188. 

6  Azevedo  Albuquerque,  Endoscopia  do  Appareilho  Urinaria  (These  de  Porto, 
1903). 


136  GONORRHEA 

Ch.  Stern  ^  (of  Hartford),  Paul  Asch^  (of  Strassburg),  Luys,^  Wossidlo,"* 
Von  Friscli,^  Wormser,^  Suarez  de  Mendoza'^  (of  Madrid),  Oberlander  and 
Kollmann,^  and  of  Fraisse,®  deserve  special  mention. 


Description  of  Luys's  Urethroscope, 

My  urethroscope  consists  of  two  distinct  portions — ^the  urethroscopic 
tubes  witK  their  metal  pilots,  and  the  handle,  or  illuminator. 

1.  Urethroscopic  Tubes. — My  tubes  are  not  perfectly  cylindrical.  A 
longitudinal  groove  runs  along  one  of  the  walls,  which  receives  the  lamp 
and  its  holder.  The  lamp  is  thus  hidden  within  the  wall  of  the  instrument, 
instead  of  protruding  into  its  lumen.  This  arrangement  increases  the  field 
of  vision. 

One  of  the  two  extremities  of  the  urethroscopic  tube  articulates  with 
the  handle  by  means  of  a  notch  and  a  short  stem,  which  fit  on  to  corre- 
sponding devices  on  the  handle,  and  are  secured  by  a  screw.  The  other 
end  is  rounded  off,  and  thus  it  differs  from  the  tubes  commonly  used  in 
Germany,  which  are  liable  to  injure  the  mucous  membrane  of  the  urethra. 

At  the  lower  part  of  the  tube  a  longitudinal  depression  is  shown,  in  which 
the  lamp  and  its  holder  are  carried. 

Length  of  the  Tubes. — I  generally  use  tubes  of  different  length,  according 
to  the  portion  of  the  urethra  which  I  wish  to  examine. 

The  long  tubes  are  14  centimetres  long,  and  are  destined  for  the  posterior 
urethra. 

The  short  tubes  for  the  penile  urethra  measure  only  7  centimetres. 

The  medium-sized  tubes,  which  are  most  often  used,  are  13  centimetres 
long,  and  allow  one  to  explore  the  whole  anterior  urethra. 

^  Ch.  Stern,  "  On  the  Use  of  the  Urethroscope  in  Diagnosis,"  Transactions  of  the 
Connecticut  State  Medical  Society,  1906,  pp.  137-145. 

2  Paul  Asch,  "  Urethroskopische  Beitrage  zur  Diagnose  Therapieund  Prognose  des 
Trippers  und  seiner  Folgen,"  Zeitschrift fur  Urologie,  1907,  Bd.  i.,  Heft  4. 

3  Luys,  "  Diagnostic  et  Traitement  Uretroscopique  des  Uretrites  Chroniques," 
Presse  Medicale,  April  22,  1903;  Compte  Rendu  de  V Association  Frangaise  d' Urologie, 
1903,  p.  789 ;  Endoscopic  de  V  Uretre  et  de  la  Vessie,  Paris  (Masson),  1905,  epuise ;  Explora- 
tion de  V A'p'pareil  JJrinaire,  1st  and  2nd  edit.,  1909,  Paris  (Masson). 

*  Wossidlo,  Die  Gonorrhoe  des  Mannes  und  ihre  Komplicationen,  Berlin  (Otto 
Emslin),  1903;  et  Zweite  Aufiage,  Leipzig  (GeorgTheime),  1909. 

5  Von  Frisch  et  Zuckerkandl,  Handbuch  der  Urologie,  Erster  Band,  p.  550  et  suiv, 
Wien  (Holder),  1904. 

*  Wormser,  Journal  des  Praticiens,  August  4, 1906. 

'  Suarez  de  Mendoza,  "  Diagnostico  y  Tratamiento  de  las  Enfermedades  de  las  Vias 
Urinarias,"  Perlado,  Paez,  Madrid,  1908. 

*  Oberlander  et  KoUmann,  Die  Chronische  Gonorrhoe  der  Blanrdichen  Harnrdhre, 
und  ihre  Komplicationen,  Zweite  Auflage,  Leipzig  (Georg  Thieme),  1910. 

9  Fraisse,  Gonorrhee  Ghronique  de  V Homme,  Paris  (Maloine),  1910. 


URETHROSCOPY 


137 


Their  Lumen. — Oberlander  and  Kollmann  have  examined  300  patients^ 
for  the  purpose  of  ascertaining  the  best  width  for  urethroscopic  tubes; 
2  to  3  per  cent,  of  their  cases  had  too  narrow  a  meatus  to  admit  No.  23. 
In  most  instances  (69  to  70  per  cent.)  a  tube  No.  27,  or  even  No.  29,  could 
be  passed. 

One  therefore  has  to  use  No.  23  in  10  per  cent,  of  all  cases,  and  No.  25 
in  25  per  cent. 

It  follows  that  most  patients  have  a  meatus  of  sufficient  width  to  admit 
at  least  No.  25.  My  personal  observations  are  in  complete  agreement  with 
these  figures,  and  I  usually  select  a  tube  No.  26. 


Fig.  80. — Luys"s  Long  Urethboscopic  Tube,  with  its  Pilot. 

Generally  speaking,  it  is  of  advantage  to  use  the  largest  size  possible. 
One  thus  obtains  a  larger  field.  The  folds  of  the  mucous  membrane  are 
spread  out  better,  and  allow  one  to  see  lesions  which  would  remain  hidden 
otherwise. 

Material  used. — My  tubes  are  made  of  metal,  and  are  nickel-plated. 
They  are  thus  easily  cleaned,  sterilized,  and  handled. 

Some  authorities  recommend  glass  tubes,  because  this  substance  is  a 
non-conductor  of  electricity.    It  is  true  that  a  short  circuit  is  apt  to  be 


£^a 


Fig.  81. — Lirys's  Short  Urethroscopic  Tube,  with  its  Lamp. 


made  if  one  moves  live  wires  about  within  the  urethra,  and  happens  to 
touch  the  wall  of  the  metal  tube;  but  this  little  accident  is  avoidable  by 
careful  manipulation,  and  it  certainly  is  in  no  way  comparable  to  the  danger 
of  breaking  the  glass  tube  when  it  is  inside  the  urethra.  A  misadventure 
of  this  kind  might  easily  lead  to  a  serious  calamity, 

I  also  cannot  share  Griinf eld's  predilection  for  vulcanite  tubes. 

The  metal  pilots  of  my  tubes  differ  from  those  made  in  Germany  by 
being  solid  nickel-plated  rods.     They  are  easier  to  handle,  and  can  be 

^  Vide  De  Keersmaecker  and  Verhoogen,  loc  cit. 


138 


GONOREHEA 


withdrawn  more  readily  once  tlie  tube  has  been  introduced.  In  the  first 
models  my  pilots  had  a  longitudinal  groove  running  along  their  whole 
length,  which  allowed  the  air  to  enter  when  the  pilot  was  withdrawn.  This 
arrangement  prevents  the  aspiration  of  the  mucosa 
into  the  tube,  and  avoids  injury  and  pain.  It  has 
become  unnecessary,  and  has  been  discarded  in 
the  recent  models,  since  the  tubes  have  been  fitted 
with  a  groove  for  the  lamp. 

2.  The  Handle. — The  handle  of  my  urethro- 
scope consists  of  a  metal  stem  of  suflB.cient  length 
to  be  held  comfortably.  It  is  fitted  with  a  switch, 
which  allows  one  to  cut  off  the  current.  At  its 
lower  end  are  two  holes  which  receive  the  electric 
wires,  and  its  upper  end  carries  a  magnifying-glass 
which  can  be  easily  moved  to  the  right  or  to  the 
left.  The  lens  is  supported  in  a  metal  clip,  from 
which  it  can  be  easily  removed  if  one  wishes  to  use 
a  longer  or  a  shorter  tube.  One  substitutes  the 
lens  required,  which  has  a  focal  length  correspond- 
ing to  the  length  of  the  tube  about  to  be  used. 
The  small  electric  lamp  is  fixed  to  the  upper 
extremity  of  the  handle.  For  the  different  tubes,  lamps  mounted  on 
holders  of  different  lengths  are  supplied.  The  length  of  a  holder  is  such 
as  to  bring  the  lamp  exactly  opposite  the  end  of  the  endoscopic  tube  with- 
out touching  the  urethral  mucous  membrane. 


Fig.  82.  —  Handle  of 
LuYs's  Urethroscope, 
WITH  ITS  Lens  and 
Electric  Wires. 


Fig.  83. — Side- View  of  Ltjys's  Urethroscope, 
completely  mounted. 


The  lamps  are  interchangeable  within  a  few  seconds,  and  are  disinfected 
in  the  same  manner  as  an  ordinary  cystoscope — namely,  by  the  action  of 
formalin  vapours — whilst  the  endoscopic  tubes  are  sterilized  by  boiling. 


UKETHROSCOPY 


139 


This  is  the  instrument  with  which  I  have  always  operated,  and  with 
success.  There  is  no  danger  of  burning  the  patient.  The  lamps  which  we 
use  are  so-called  cold  lamps,  which  give  of?  no  appreciable  heat  when  they 
are  new.  During  my  long  experience  I  have  never  come  across  a  patient 
who  complained  of  a  disagreeable  sensation  of  heat  during  the  urethroscopic 
examination. 

It  is  advisable  to  change  the  lamps  frequently,  and  to  keep  a  stock  of 
them  in  hand ;  for  they  "  go  "  quickly,  and  after  prolonged  use  they  cease 
to  be  cold  lamps,  and  give  off  heat.  "When  purchasing  the  lamps,  it  is  well 
to  select  the  smallest  ones,  and  to  make  sure  that  they  are  cold  when  burning. 


Fig.  84. 

This  figure  shows  how  the  endoscopic  tube  is  caught  and  stopped  by  the 
projecting  verumontanum. 

With  my  instrument,  intra-urethral  manipulations  can  be  carried  out 
without  having  to  withdraw  the  lamp.  They  are  therefore  comparatively 
easy,  and  are  constantly  controlled  by  sight. 

The  illumination  of  the  urethral  mucosa  is  perfect,  and  infinitely  more 
powerful  than  that  obtained  by  instruments  with  external  illumination. 


Special  Urethroscopes  for  the  Posterior  Urethra. 

Owing  to  the  projection  of  the  verumontanum,  the  examination  of  the 
posterior  urethra  presents  special  difficulties. 

An  ordinary  straight  tube  is  caught  when  it  reaches  the  verumontanum, 


140 


GONORKHEA 


and  makes  it  bleed  a  little  {vide  Fig.  84).  This  hemorrhage  is  of  no  conse- 
quence, but  generally  there  is  also  some  bleeding  from  the  rest  of  the  pos- 
terior urethra  in  these  cases,  and  then  one  may  be  unable  to  see  anything. 

For  this  reason  a  number  of  authors  have  endeavoured  to  introduce 
improved  instruments,  which  unfold  and  separate  the  walls  of  the  posterior 
urethra.  Goldschmidt  used  water  for  this  purpose;  Wossidlo  inflates  the 
urethra  with  air,  like  Von  Antal. 

After  having  given  these  various  urethroscopes  a  trial,  I  have  given 
them  up.  I  much  prefer  my  simple  endoscope  to  these  compUcated  instru- 
ments, and  I  find  that  it  answers  just  as  well  if  handled  carefully,  not  to 
mention  its  advantages,  such  as  its  simple  and  solid  construction,  and  the 
ease  with  which  it  is  manipulated. 

Goldschmidt's  Irrigation  Urethroscope  for  the  Posterior  Urethra.— 
This  interesting  instrument  is  of  great  service  in  examinations  of  the  pos- 


FiG.  85. — Lamp  of  Le  Fur's  Urethroscope. 


terior  urethra.  Its  construction  reminds  one  of  an  older  apparatus  invented 
by  Le  Fiir.  This  author  showed  in  1903  a  new  urethroscope,  in  which  the 
lamp  was  fixed  to  the  far  end  of  the  tube.  This  arrangement  was  copied 
from  the  ordinary  cystoscope,  and  marked  a  new  departure. 

The  advantage  of  this  instrument  was  that  the  lumen  of  the  tube  was 
perfectly  free ;  but,  unfortunately,  the  lamp  threw  its  light  directly  into  the 
eye  of  the  observer,  and  thus  made  it  impossible  for  him  to  see  the  details 
of  the  urethral  mucous  membrane  distinctly.^ 


dC: 


A 


M 


4 


Fig.  86. — Le  Fur's  Urethroscope. 


Goldschmidt  of  Berlin ^  adopted  the  principle  of  this  instrument,  and 
combined  it  with  that  of  the  irrigation  cystoscope.  He  thus  invented  an 
apparatus  which  in  certain  special  cases  gives  excellent  results.  The 
urethra  is  distended  by  a  current  of  water  running  from  an  irrigator,  and 
is  then  examined. 

1  Le  Fiir,  C.  R.  de  VAss.  Frang.  d'  Urologie,  p.  784. 

2  Goldschmidt,  "Die  Endoskopie  der  Harnrohre,"  Berl.  Klin.  Woch.,  1906,  No.  6; 
"  Die  Irrigations-Urethroskopie,"  Folia  Urologica,  von  James  Israel,  vol.  i.,  1907,  Nos. 
1  and  2. 


URETHROSCOPY 


141 


His  outfit  comprises  two  instruments,  one  for  the  anterior  and  one  for 
the  posterior  urethra.  Each  one  has  its  optical  portion,  which  enlarges  the 
visual  field  and  magnifies  the  images. 

The  instrument  is  used  as  follows:  The  patient  empties  his  bladder  in 
the  normal  way,  and  is  put  into  the  position  for  cystoscopy — head  down, 
body  horizontal,  the  pelvis  up  to  the  edge  of  the  table,  the  thighs  flexed, 
and  the  heels  supported  by  stirrups. 

The  urethroscope  is  sterilized  by  boiling,  and  fitted  with  its  pilot.     It 


Fig.  87. — Goldschmibt's  Ubethroscope  eoe  the  Postebior  Urethra. 

is  then  lubricated  with  glycerine,  and  passed  into  the  posterior  urethra, 
which  it  enters  without  difficulty,  owing  to  its  curve. 

The  electric  wires  are  attached,  and  the  tap  at  the  upper  part  of  the 
instrument  is  connected  with  a  reservoir  which  contains  lukewarm  water, 
and  is  placed  about  6  feet  above  the  level  of  the  bed.  The  pilot  is  then 
withdrawn,  and  replaced  by  the  optical  portion.  One  now  opens  the  tap, 
switches  on  the  light,  and  examines  the  posterior  urethra.  By  drawing  the 
optical  portion  gently  to  and  fro,  the  posterior  urethra  can  be  examined  in 
its  entire  length.     The  circulating  water  naturally  flows  into  the  bladder, 


Fig.  88. — Goldschmidt's  Urethroscope  for  the  Anterior  Urethra. 


and  thus  the  patient  finds  it  necessary  after  a  certain  time  to  empty  his 
bladder.  One  switches  of!  the  current,  withdraws  the  optical  portion,  and 
allows  the  water  to  run  out. 

The  principle  of  the  urethroscope  for  the  anterior  urethra  is  similar. 

Advantages. — The  great  advantage  of  this  instrument  is  that  a  complete, 
examination  of  the  posterior  urethra  can  be  made,  which  is  not  interfered 
with  by  the  presence  of  blood.  The  latter  is  constantly  washed  away  by  the 
circulating  water.  Moreover,  the  walls  of  the  urethra  are  well  separated, 
and  are  thus  well  shown. 


142  GONOEEHEA 

Lastly,  the  images  obtained  are  considerably  magnified.  Even  the 
smallest  details  are  thus  visible.  Small  polypi  float  in  the  water,  and  are 
very  easily  recognized. 

Drawbacks. — ^Unfortunately,  the  drawbacks  are  more  numerous  than 
the  advantages. 

Firstly,  the  apparatus  is  very  complicated.  The  handling  of  the  optical 
portion  and  the  circulation  of  water  render  its  use  somewhat  difficult. 

Secondly,  the  urethroscopic  images  do  not  correspond  to  the  actual 
condition  present.  The  whole  mucosa  is  pale,  bloodless,  and  anemic,  owing 
to  the  pressure  of  the  circulating  water. 

Thirdly,  it  is  impossible  to  obtain  a  general  view  of  the  posterior  urethra 
with  this  instrument.  One  wall  only  can  be  seen  at  a  time,  because  the 
lamp  takes  up  a  part  of  the  opening  in  the  endoscopic  tube. 

Fourthly,  the  wpper  wall — the  region  above  the  verumontanum — cannot  be 
examined  at  all.     This  is  the  chief  drawback  of  the  instrument. 

Fifthly,  local  treatment  of  the  posterior  urethra  (local  applications, 
cauterizations)  is  very  difficult  to  carry  out  with  Goldschmidt's  apparatus. 

To  resume:  Goldschmidt's  irrigation  urethroscope  is  an  excellent 
diagnostic  instrument,  but  it  should  be  reserved  for  special  cases  in  which 
a  very  accurate  investigation  of  the  posterior  urethra  is  necessary. 

This  instrument  has  undergone  some  interesting  modifications  in  the 
hands  of  Dr.  Alfred  Rothschild.^ 


Fig.  89. — Buerger's  Cysto-Urethroscope. 

Buerger's  Cysto-Urethroscope. — Goldschmidt's  method  has  been  de- 
veloped further  by  Dr.  Leo  Buerger,  of  New  York.^  He  finds  that  Gold- 
schmidt's instrument  is  difficult  to  handle,  and  that  it  is  apt  to  injure  the 
posterior  urethra.  Moreover,  its  field  of  vision  is  too  small,  and  its  images 
are  distorted. 

His  own  instrument  is  based  on  the  same  principle  as  Nitze's  cystoscope, 
and  is  free  from  some  of  the  defects  mentioned.  The  images  are  enlarged 
by  a  prism  placed  on  the  upper  wall  of  the  far  end,  as  shown  in  Fig.  89, 
which  gives  a  view  of  the  optical  portion. 

1  Rothschild,  Zeits.  f.  Urologie,  1908,  vol.  ii.,  p.  1000;  Verhandlung.  d.  Deutsch. 
Gesdl.f.  Urol,  April,  1909,  p.  458. 

2  Leo  Buerger,  "  On  Methods  of  Posterior  Urethroscopy,  with  a  Description  of  a 
New  Cysto-Urethroscope."     (Reprinted  from  Amer.  Journ.  of  Surgery,  May,  1910.) 


URETHROSCOPY 


143 


The  instrument  and  its  pilot  are  introduced  into  the  bladder,  which  is 
irrigated  through  the  former.  The  optical  portion  is  then  introduced.  The 
circulation  of  water  is  assured  through  a  side-tube,  which  is  connected  with 
an  irrigator.  The  trigone  of  the  bladder  and  the  posterior  urethra  are 
inspected,  small  quantities  of  water  being  injected  on  and  ofi;  50  to  150 
c.c.  of  boric  acid  solution  are  suJ0S,cient. 

Owing  to  the  small  size  of  the  window,  the  apparatus  can  be  turned  in 
all  directions. 


Fig.  90. — Wossidlo's  Urethroscope  for  the  Posterior  Urethra. 

Wossidlo  suggested  in  1908^  an  instrument  for  the  posterior  urethra 
which  inflated  the  passage  with  air.  In  his  last  models  he  adopted  the 
water  circulation. 


Personal  Experiences  on  the  Urethroscopie  Examination  of  the 
^.^P*  Posterior  Urethra. 

The  excellent  results  which  I  had  obtained  with  my  direct  vision  cjsto- 
scope  for  the  bladder,  and  with  my  rectoscope  for  the  rectum,  led  me  to 
adapt  the  same  principle  to  the  examination  of  the  posterior  urethra.    J 

1  Wossidlo,  Zeits.f.  Urologie,  1908,  p.  2i3 ;  Deutsch.  Med.  Woch.,  1910,  No.  7. 


144 


GONORRHEA 


thus  undertook  a  series  of  experiments  and  researches  for  the  examination 
of  the  posterior  urethra. 

I  had  a  tube  made  which  was  similar  to  that  of  my  direct  vision  cysto- 
scope — i.e.,  a  tube  fitted  on  its  under-surface  with  a  very  narrow  channel 
which  had  an  opening  at  the  far  end  of  the  urethroscopic  tube,  and  was 
fitted  with  two  taps  at  its  other  end.  Through  it  liquids  could  be  aspirated 
by  means  of  a  filter  pump,  or  air  could  be  insufflated  by 
means  of  bellows.  The  illumination  was  effected  by 
means  of  a  small  lamp  on  a  long  holder.  The  outer 
opening  of  the  endoscopic  tube  was  closed  hermetically 
by  a  small  glass  window  which  adapted  itself  by 
pressure.  This  window  was  only  to  be  applied  when 
one  wished  to  inflate  the  posterior  urethra  with  air. 


W 


Fig.  91. — Luys's  Direct  Vision  Cystoscope  (Male  Pattern). 

Advantages  of  the  Instrument.  —  Whenever  I  inflated  the  posterior 

urethra  with  air,  I  noticed  that  the  vision  was  perfect.  Something  like  a 
cloud  seemed  to  disperse ;  a  shadow  seemed  to  pass  and  to  make  room  for 
a  bright  illumination  of  the  verumontanum.     Moreover,  I  very  seldom 


!FiG.  92. — ^TijBE  OF  LuYs's  Direct  Vision  Cystoscope, 

WITH  ITS   COUDE   PlLGT  (MaLE  PaTTERN). 


required  now  mounted  swabs.  The  pressure  of  the  air  was  sufl&cient  to 
check  any  oozing  and  any  pathological  secretion.  As  the  walls  of  the 
posterior  urethra  were  well  separated,  I  obtained  a  splendid  general  view 
of  it.  Lastly,  there  was  this  advantage  over  the  urethroscopes  for  the 
posterior  urethra  which  are  worked  with  a  water  circulation — ^that  there 


UEETHROSCOPY  145 

were  no  air  bubbles  in  the  water  to  interfere  with  the  clearness  of  the  pic- 
tures. The  colour  of  the  mucosa  was  hardly  altered.  It  was  practically 
normal,  and  not  anemic,  as  in  the  case  of  the  instruments  with  a  water 
circulation. 

Drawbacks. — The  chief  drawback  was  that  the  air  used  for  dilating  the 
posterior  urethra  found  its  way  into  the  bladder.  This  viscus  soon  became 
distended,  and  the  desire  to  micturate  supervened.  In  cases  with  a  small 
prostate,  nothing  was  then  easier  than  to  push  the  urethroscopic  tube  into 
the  bladder  and  to  relieve  the  distension.  But  when  the  gland  was  large, 
I  encountered  considerable  difficulty  in  trying  to  reach  the  bladder.  The 
prostate  and  the  verumontanum  formed  a  kind  of  valve.  The  air  entered, 
but  it  did  not  come  out  again. 

I  remedied  this  defect  by  modifying  my  original  design,  and  by  making 
a  small  opening  at  the  vesical  end.  In  this  way  the  air  which  was  under 
pressure  in  the  bladder  could  escape  through  the  taps  on  the  outer  end  of 
the  urethroscopic  tube. 

This  instrument  gave  a  very  good  view  of  the  posterior  urethra ;  but  one 
must  admit  that  such  exploratory  measures  are  exceptional,  whether  one 
uses  this  instrument  or  another  model. 

In  the  overwhelming  majority  of  cases,  my  simple  straight  tube  is  suffi- 
cient for  a  complete  examination  of  the  posterior  urethra,  providing  one 
uses  it  after  having  previously  dilated  the  urethra  with  curved  metal  sounds. 
One  then  obtains  a  good  view,  and  can  work  under  practically  the  same 
advantageous  conditions  as  with  special  instruments,  without  having  to 
suffer  from  their  drawbacks.^ 

The  Supply  of  Electric  Current. 

The  electric  current  required  for  the  urethroscopic  lamps  may  be 
obtained  from  a  variety  of  sources. 

One  can  take  it  directly  from  the  main  which  supplies  the  house,  in 
which  case  a  resistance  has  to  be  interposed,  such  as  one  of  the  rheostats 
shown  in  Figs.  93,  94,  and  96. 

Or  a  small  portable  battery  (Fig.  95)  may  be  used.  These  small  cells 
are  rapidly  exhausted,  but  they  can  be  replaced  easily,  and  take  up  so  little 
room  that  one  can  carry  them  in  one's  pocket. 

Another  apparatus  which  may  be  of  interest  to  those  who  have  no 
electric  light  in  their  house  is  the  portable  dynamo  devised  by  Dr.  Sigurta 
of  Milan. 

The  instrument  consists  of  a  case  which  encloses  a  small  dynamo  which 

1  Vide,  as  regards  the  technique  in  the  case  of  man :  Luys,  Exploration  de  rAppareil 
Urinaire,  2nd  edit.,  Paris  (Masson),  1909. 

10 


146 


GONORRHEA 


'\        '^% 


Fig.  93. — Rheostat  for  Light  and  Cautery,  suitable  for  the  Current  from 

THE  Main. 


Fig.  94. — Rheostat  for  Light  and  Cautery,  suitable  for  the  Current  from. 

THE  Main.     (Gaiffe.) 


URETHROSCOPY 


147 


is  worked  by  turning  a  handle.    This  duty  can  easily  be  performed  by  an 
unskilled  assistant.^ 

I  hope  that  the  manipulative  ease  of  my  urethroscope,  its  precision, 


Fig.  95.— Small  Portable       Fig.  96.— Rheostat  for  Light  only,  suitable  for 
Pocket  Battery.  the  Current  prom  the  Main.      (Lowenstein.) 

and  the  accurate  diagnostic  information  obtained  through  it,  will  induce 
many  medical  men  to  devote  their  attention  once  more  to  urethroscopy. 
Even  firm  believers  in  this  method  of  investigation  have  given  it  up  after 


Fig.  97. — Dr.  Sigurta's  Portable  Dynamo  for  Electric  Light. 

their  first  attempts,  owing  to  the  diflB.culties  encountered  with  the  earher 
instruments. 

Up  to  now  very  little  urethroscopic  work  has  been  done  in  France, 

1  Sigurta,  Estratto  dagli  Atti  ddla  Societa  Milanese  di  Medicina  e  Biologia,  vol.  iii., 
fasc.  v. 


148  GONOKEHEA 

mainly  for  the  reason  that  the  apparatus  at  one's  disposal  has  been  so 
complicated  and  clumsy. 

My  urethroscope  is  simple  and  practical,  and  gives  a  good  view  of  the 
urethral  lesions.  This  diagnostic  method  should  therefore  be  resorted  to 
more  frequently.  It  should  become  a  matter  of  routine,  just  as  the  explora- 
tion with  the  olivary  bougie. 

The  Technique  of  Urethroscopy. 

Preparation  of  the  Instruments. 

The  couch  used  for  urethroscopic  examinations  should  be  high,  and  fitted 
with  a  movable  back  if  possible.  Its  front  legs  should  carry  foot-rests  on 
which  the  patient  can  put  his  feet  (Fig.  98). 


Fig.  98. — Consulting-Room  Table  foe  Urethroscopic  Examination. 

The  urethroscope  is  mounted  and  tested.  The  end  of  the  lamp-holder 
which  fits  into  the  handle  carries  a  little  notch,  which  should  be  in  the 
free  part  of  the  groove  on  the  handle.  The  lamp  is  then  in  its  proper 
position,  and  the  special  screw  is  screwed  down. 


UEETHKOSCOPY  149 

One  should  also  see  that  the  lamp  and  its  holder  form  a  straight  line. 
Any  curve  or  bend  reduces  the  field  of  vision.  In  addition,  the  bulb  of  the 
lamp  should  be  horizontal,  and  closely  applied  to  the  wall  of  the  urethro- 
scopic  tube.  If  these  precautions  are  neglected,  the  surface  visible  is 
reduced,  and  the  endoscopic  manoeuvres  become  diflS.cult. 

The  electric  current  is  best  taken  from  the  main,  in  which  case  a  resistance 
has  to  be  inserted  {vide  Figs.  93,  94,  and  96).  One  can  also  use  an  accu- 
mulator or  a  portable  battery.  The  lamp  is  gradually  made  incandescent 
until  it  gives  a  white  light. 

The  endoscofic  tubes  are  carefully  chosen  for  each  case.  If  one  only 
wishes  to  examine  the  penile  portion  of  the  anterior  urethra,  a  short  tube, 


Fig.  99. — Swab  mounted  on  a  Cane  Hoij)er. 

about  7  centimetres  long,  is  best.  For  the  whole  anterior  urethra,  tubes 
13  centimetres  long  should  be  chosen.  For  an  examination  of  the  posterior 
urethra  and  of  the  prostatic  lesions,  14-centimetre  tubes  are  required. 

One  naturally  selects  a  lamp  which  has  a  holder  of  the  same  length  as 
the  tube  about  to  be  used. 

The  sizes  most  commonly  used  are  No.  24,  No.  26,  and,  if  possible.  No.  28. 

The  lens,  which  corresponds  to  the  length  of  the  tube  which  one  wishes 
to  use,  is  fitted  on  to  the  handle. 


Fig,  100. — SPECiAii  Urethral  Forceps  eor  Intra- 

Urethral  Interventions. 

To  the  right  of  the  surgeon  the  necessary  special  instruments  are  placed 
in  order  to  enable  him  to  treat  as  well  as  to  diagnose.  The  instruments 
required  are— Mounted  swabs  (Fig.  99),^  long  urethral  forceps  (Fig.  100) 
for  collecting  any  swabs  which  may  come  off  their  holders,  caustic  on  a 
holder,  galvano-cautery  points,  and  Kollmann's  electric  needle. 

^  These  mounted  swabs  are  made  of  wood,  or  cane,  or  bamboo,  surrounded  at  their 
ends  with  cotton-wool,  and  are  best  sterilized  by  dry  heat.  Formalin  vapours  are  not 
well  borne  by  the  urethral  mucous  membrane. 


150 


GONOEKHEA 


Peepaeation  of  the  Patient. 

The  patient  should  take  off  all  Ms  clothes  except  his  shirt,  and  should 
not  have  made  water  for  several  hours.  He  should  lie  on  the  couch  in  such 
a  way  that  his  feet  rest  on  stirrups  and  that  his  legs  hang  down.  The  pelvis 
should  touch  the  edge  of  the  couch.  For  the  examination  of  the  posterior 
urethra  the  position  of  the  body  should  be  almost  horizontal,  and  this 
position  may  be  retained  for  the  exploration  of  the  anterior  urethra. 


Fig.  101. — ^Examination  of  the  Anteeior  Urethra. 


However,  if  one  wishes  to  examine  the  posterior  urethra  very  thoroughly, 
it  is  advisable  to  raise  the  thighs  and  legs  until  they  are  on  a  level  with  the 
pelvis — i.e.,  the  patient  should  be  in  the  position  which  is  recommended  for 
ordinary  cystoscopy. 

The  glans  and  meatus  are  then  cleansed. 

In  a  previous  visit  one  should  have  ascertained  that  the  meatus  is 
sufficiently  large,  and  that  there  are  no  strictures  present  which  would  inter- 
fere with  the  passing  of  the  urethroscopic  tube.  In  a  normal  organ  the 
meatus  is  always  the  narrowest  part  of  the  urethra.     In  cases  of  atresia 


UKETHROSCOPY  151 

of  the  meatus,  a  meatotomy  should  be  done  previously  in  order  to  allow 
the  urethroscopic  tube  to  pass  easily  and  without  pain. 

Unless  there  are  special  indications,  no  fluid  should  be  injected  into 
the  urethra,  because  it  would  wash  away  pathological  secretions,  such  as 


Fig.  102. — ExAJvnisrATioN  of  the  Postebior  Urethra. 

those  of  Littre's  glands,  which  it  is  well  to  see.  The  urethroscopic  examina- 
tion should  therefore  be  carried  out  before  the  patient  has  made  water. 
Once  the  investigation  is  terminated,  the  patient  should  cleanse  his  urethra 
by  a  normal  micturition. 

Some  nervous  and  highly  sensitive  patients  require  their  urethral  mucous 
membrane  to  be  anesthetized,  and  it  seems  to  us  best  to  inject  into  the 


Fig.  103.— Syringe  op  10  C.C.  Capacity,  which  can  be  steriIiIzeb  by  boimng, 
FOR  the  Intra-Urethral  Injection  of  Stovain  or  Cocain. 

closed  canal  8  to  10  c.c.  of  a  1  per  cent,  solution  of  stovain  for  that  purpose. 
One  should,  however,  avoid  this  procedure,  which  is  carried  out  by  means  of 
a  special  syringe,  whenever  possible.  The  stovain  produces  a  temporary 
anemia  of  the  mucosa,  and  thus  alters  its  aspect. 


152  GONORRHEA 

Operative  Technique. 

The  tube  and  pilot  whicli  have  been  selected  for  a  given  case  are  freely 
lubricated  with  sterilized  glycerine.  This  substance  is  to  be  preferred, 
because  it  does  not  affect  the  transparency  of  the  urethral  mucous  mem- 
brane, and  does  not  interfere  with  the  view.  The  endoscopic  tube  is  intro- 
duced according  to  the  principles  of  straight  catheterization.  It  is  pushed 
on  gently  into  the  penis  as  far  as  the  membranous  region,  and  its  passage 
at  this  point  is  facilitated  by  firm  downward  pressure  with  the  left  hand. 
The  integuments  of  the  hypogastric  region  are  thus  drawn  downwards,  and 
the  subpubic  ligaments  are  stretched  and  lowered. 


Fig.  104. — Intboduction  of  the  Urethboscopic  Tube  into  The  Postebiob 

Ueethba. 

The  passing  of  a  straight  tube  has  been  considered  by  some  to  be  a 
matter  of  exceptional  difficulty.  A  few  have  even  gone  as  far  as  to  declare 
the  previous  passing  of  a  whip  bougie  necessary.  There  is  no  need  for  this. 
As  we  have  pointed  out  above,  the  urethra  should  never  be  submitted  to 
urethroscopic  examinations  unless  it  has  been  sufficiently  dilated  previously. 
It  is  useful  and  successful  only  under  that  condition. 

Furthermore,  one  should  not  forget  to  put  the  patient  in  the  proper 
position :  he  should  lie  on  the  couch  with  his  pelvis  on  the  edge  of  the  table, 
and  his  feet  supported  by  foot-rests.  The  surgeon  should  stand  between 
the  legs  of  the  patient,  and  should  hold  the  penis  vertically  whilst  he  intro- 
duces the  instrument  into  the  penile  urethra.     As  the  tube  passes  down  the 


URETHROSCOPY 


153 


urethra,  the  direction  is  made  to  approach  more  and  more  the  horizontal 
plane,  and  when  the  tip  of  the  pilot  has  reached  the  membranous  urethra, 
the  instrument  is  pushed  on  horizontally.  After  a  few  gentle  tentative 
efforts  it  enters  the  posterior  urethra  with  great  ease.  Suddenly  all  re- 
sistance ceases.  One  now  stops,  for  one  has  gone  slightly  too  far  and 
reached  the  bladder,  as  proved  by  the  flow  of  urine  from  the  tube. 


Fia.  105. 

The  urethroscopic  tube  having  been  introduced,  the  pilot  is  withdrawn  and 
the  handle  is  attached  (lamp  downwards). 


The  instrument  is  then  gently  withdrawn  for  a  slight  distance,  until 
no  more  urine  comes  away.  The  end  of  the  tube  is  outside  the  bladder 
again,  and  the  pilot  is  removed.  Any  secretions  which  may  be  present  in 
the  posterior  urethra  are  then  wiped  away  with  mounted  swabs,  and  once 
the  canal  is  su£S.ciently  dry,  one  inserts  the  lamp,  the  handle  pointing 
downwards.    In  this  position  the  introduction  of  the  lamp  is  easiest. 

It  is,  however,  desirable  that  the  lamp  should  be  on  the  upper  wall  of 
the  tube,  and  therefore  one  turns  the  latter  by  means  of  its  handle  through 


154 


GONOKEHBA 


an  angle  of  180°.  Omitting  this,  tlie  lamp  hides  a  portion  of  the  lower 
and  more  important  wall  of  the  urethra,  and  comes  into  contact  with 
any  secretions  which  may  have  collected  there.  This  could  interfere  with 
the  light. 

When  the  lamp  is  above  and  in  its  proper  position,  it  inundates  the 
whole  fundus  of  the  tube  with  light.  The  verumontanum,  which  lies  below, 
can  be  swabbed  clean  under  the  control  of  the  eye,  and  be  freed  from  any 
secretions  which  might  interfere  with  the  view. 


Fig.  106. 

For  the  examination  of  the  posterior  urethra  the  handle  of  the  urethroscope  should  be 
turned  upwards.  The  lamp  is  then  also  above,  beyond  the  reach  of  the  secretions 
from  the  urethra,  which  by  gravity  collect  in  the  lower  part  of  the  tube. 


One  then  gently  and  gradually  withdraws  the  tube  and  inspects  the 
dif!erent  parts  of  the  passage. 

The  ease  with  which  the  mucous  membrane  of  the  urethra  can  be  cleaned 
by  means  of  swabs  is  remarkable.  There  is  no  need  to  withdraw  the  lamp 
each  time  one  wishes  to  touch  the  mucosa.  This  is  a  great  advantage  over 
the  older  instruments,  such  as  Ober lander's.  All  intra-urethral  manipula- 
tions (swabbing,  cauterization,  etc.)  are  carried  out  under  the  control  of  the 
eye.    They  thus  become  easy  and  accurate. 


URETHEOSCOPY 


155 


Contra-Indications. 

Urethroscopy  should  not  be  resorted  to  indifferently  in  all  cases  of 
urethritis.  When  a  recent  or  acute  inflammation  is  present,  one  should 
follow  the  general  rule,  and  refrain  from  passing  an  instrument  into  the 
urethra.  All  urethroscopic  examinations  should  be  postponed  until  all 
pain  during  micturition  and  erection  has  disappeared,  and  until  the  urine 
has^become  clear. 

One  should  also  wait  if  the  urethra  is  still  very  tender  as  a  result  of  an 
energetic  treatment. 


Fig.  107. — Intra-Ueethral  Manipulations. 
The  mucous  membrane  is  being  dried  by  means  of  a  mounted  swab. 


It  should  also  be  a  general  rule  never  to  urethroscope  a  patient  unless  one 
is  acquainted  with  the  lumen  of  his  urethra. 

It  is  reckless  to  urethroscope  immediately  a  patient  whom  one  sees  for 
the  first  time.  A  small  meatus  or  an  unsuspected  stricture  within  the  urethra 
might  easily  veto  the  intervention,  and  cause  unnecessary  pain  and  hemor- 
rhage. 

Before  passing  an  endoscopic  tube,  one  should  always  have  examined 
the  urethra  with  an  olivary  bougie  at  a  previous  visit.     In  many  cases  it  is 


156  GONOKRHEA 

also  necessary  to  devote  a  few  visits  to  dilatation  with  metal  sounds  in  order 
to  prepare  the  urethra  for  the  endoscopic  examination. 

If  these  precautions  be  taken,  a  good  number  of  accidents,  such  as  edema 
of  the  lips  of  the  meatus,  hemorrhage  from  the  penis,  etc.,  will  be  avoided. 

Urethroscopic  examination  is  also  contra-indicated  if  there  are  any 
mflammatory  complications  present  in  connection  with  the  posterior  urethra, 
such  as  epididymitis,  acute  prostatitis,  etc. 

To  resume:  One  should  never  urethroscope  a  urethra  which  one  has  not 
examined  and  well  dilated  previously. 

On  the  Use  of  Adrenalin  in  Urethroscopy. 

In  certain  cases  the  urethroscopic  examination  is  rendered  impossible 
by  the  oozing  of  blood.  This  is  a  great  nuisance,  especially  if  the  bleeding 
comes  from  the  focus  which  one  intends  to  examine,  and  if  it  is  more  than 
trifling.  The  swabbing  one  instinctively  resorts  to  often  makes  matters 
worse  instead  of  improving  them.  The  application  of  a  little  adrenalin  to 
the  bleeding  spot  is  strongly  indicated  in  cases  of  this  kind,  and  stops  the 
hemorrhage  very  quickly. 

One  uses  a  mounted  swab  which  has  been  soaked  in  a  O*!  per  cent, 
solution  of  adrenalin,  and  sees  that  one  touches  the  right  spot.  Swabbing 
about  at  random  in  the  urethra  is  useless,  in  the  same  way  as  forcipressure 
is  ineffective,  unless  the  vessel  which  actually  bleeds  is  secured. 

An  important  drawback  of  this  drug  is  to  be  found  in  the  fact  that  its 
excellent  vaso-constricting  action  is  followed  by  a  vaso-dilatation,  once  its 
primary  effect  has  worn  off.  Disagreeable  secondary  hemorrhages  may 
therefore  supervene  after  its  use. 

Adrenalin  should  only  be  employed  in  small  quantities,  as  it  is  not  free 
from  danger.  One  should  never  inject  a  big  dose  into  a  closed  urethra. 
Only  a  few  drops  should  be  used,  as  otherwise  serious  accidents  may  result. 
Dr.  Johnson  of  San  Francisco^  has  published  a  case  in  point.  His  patient 
had  an  attack  of  hemorrhage  after  urethral  dilatation,  which  he  tried  to 
stop  by  filling  the  anterior  urethra  with  a  1  :  4,000  solution  of  adrenalin 
hydrochloride.  Suddenly  the  patient  became  motionless  and  livid.  His 
eyes  became  glassy,  and  nausea  and  vomiting  supervened.  Finally  he 
collapsed,  his  respirations  becoming  very  shallow,  and  his  pulse  and  heart 
sounds  imperceptible.  This  condition  lasted  for  ten  minutes  or  so,  but 
Johnson  managed  in  the  end  to  revive  him  by  the  hypodermic  injection  of 
strong  stimulants.  The  patient  remained  in  a  state  of  great  weakness  for 
several  hours,  and  was  unable  to  stand  on  his  legs  for  fully  three  hours 
after  the  event. 

^  Johnson,  Journ.  Amer.  Med.  Ass.,  October  7,  1905,  p.  1086. 


URETHEOSCOPY  157 


Urethroscopy  of  the  Urethra  in  Health  and  in  Disease. 

1.  Urethroscopy  of  the  Healthy  Urethra. 

General  Remarks. — A  few  introductory  remarks,  whicli  apply  to  the 
urethra  in  all  its  parts,  will  be  of  assistance. 

The  consistence  and  the  thickness  of  the  mucous  membrane  of  the  urethra 
vary  in  different  individuals.  The  mucosa  is  thinner  and  more  deHcate  in 
individuals  who  have  small  or  atrophied  genital  organs  than  in  vigorous 
subjects. 

The  coloration  also  differs  to  a  large  extent.  Normally  it  varies  from 
a  reddish-grey  to  a  blood  red,  according  to  the  degree  of  vascularity.  It 
differs,  also,  according  to  the  size  of  the  endoscopic  tube  used.  If  the  diam- 
eter of  the  latter  is  at  all  large,  it  presses  on  the  wall  of  the  urethra,  and 
renders  the  mucous  membrane  anemic.  If  it  exerts  more  pressure  in  one 
place  than  in  others,  a  localized  pale  patch  is  seen,  which  an  inexperienced 
observer  could  easily  mistake  for  a  diseased  area.  By  changing  the  posi- 
tion of  the  tube  such  artefacts  are  readily  recognized.  It  should  also  be 
remembered  that  the  colour  of  the  interior  of  the  urethra  changes  under 
the  influence  of  certain  drugs,  like  cocain  and  stovain,  which  render  it  pale. 
My  lengthy  experience  of  urethroscopy  has  led  me  to  the  discovery  of 
an  interesting  phenomenon :  The  colour  of  the  urethral  mucous  membrane 
appears  to  correspond  to  that  of  the  face.  I  have  noticed  frequently  the 
urethral  mucous  membrane  to  turn  pale  suddenly,  and  this  observation 
allowed  me  to  predict  that  the  patient  himself  would  turn  pale  immediately, 
and  enabled  me  to  tell  that  he  was  about  to  faint. 

All  images  seen  with  the  urethroscope  consist  of  two  essential  parts : 

The  central  figure. 

The  mucous  surface  proper. 

The  central  figure  is  formed  by  an  orifice  which  corresponds  to  the  lumen 
of  the  urethra.  Normally  the  walls  of  the  urethra  are  in  apposition,  and  the 
lumen  is  merely  a  potential  one.  When  the  endoscope  is  passed,  the  walls 
separate  from  each  other  in  a  symmetrical  fashion,  and  give  the  appearance 
of  a  long  narrow  funnel,  the  central  figure  representing  its  neck,  and  the 
walls  of  the  urethra  its  walls. 

This  funnel  is  more  or  less  evident  and  well  shaped  according  to  the 
position  of  the  urethroscopic  tube.  When  the  tube  is  unsupported,  the 
funnel  can  hardly  be  made  out.  If  one  attempts  to  push  the  tube  farther 
down  the  urethra,  the  mucous  membrane  begins  to  bulge  over  the  edge  of 
the  tube  into  its  lumen.  The  funnel  then  becomes  very  short  and  almost 
disappears.     On  the  other  hand,  if  one  withdraws  the  tube,  the  funnel 


158  •  GONOKEHEA 

becomes  deeper.  When  the  tube  is  in  the  penile  portion,  the  funnel  becomes 
almost  cylindrical  if  one  pulls  simultaneously  on  the  penis  and  the  instru- 
ment with  a  certain  amount  of  force. 

These  different  positions  can  be  taken  advantage  of  for  urethroscopic 
examination. 

For  instance,  if  one  allows  a  certain  portion  of  the  mucous  membrane 
to  bulge  into  the  lumen  of  the  urethroscope,  one  obtains  a  very  good  view 
of  its  details. 

If  one  stretches  penis  and  tube  simultaneously,  a  much  greater  surface 
of  the  mucosa  becomes  visible.  One  obtains  a  more  general  view,  and  sees 
any  lesions  present  which  project  slightly  into  the  lumen  of  the  urethra. 
This  profile  view  is  of  great  value  for  detecting  small  chronic  glandular 
lesions. 

For  a  complete  examination  both  methods  should  be  used  alternately. 

When  it  is  desired  to  examine  a  special  point  of  the  mucous  membrane, 
the  endoscopic  tube  is  inclined  on  the  axis  of  the  urethra;  its  position  is 
excentric  if  the  central  figure  is  still  visible,  and  parietal  if  it  has  disappeared. 

The  aspect  of  the  central  figure  varies  with  the  different  portions  of  the 
urethra.  At  the  glans  its  shape  is  that  of  a  small  oval  slit.  In  the  penile 
portion  it  is  like  a  point.  At  the  level  of  the  bulb  its  form  is  that  of  a 
vertical  fissure  {vide  Coloured  Plate  I.,  Fig.  4).  At  the  level  of  the  veru- 
montanum  its  aspect  is  quite  peculiar  owing  to  the  projection  of  this 
structure  {vide  Plate  I.,  Figs.  1  and  2). 

The  surface  of  the  mucosa  proper  shows  longitudinal  folds,  which  radiate 
like  the  spokes  of  a  wheel.  These  folds  are  more  or  less  marked  according 
to  the  amount  of  stretching,  and  thus  they  vary  with  the  size  of  the  tube 
employed.  In  the  healthy  urethra  they  are  well  marked,  but  they  are 
modified  under  pathological  conditions. 

The  healthy  urethral  mucous  membrane  presents  also  reddish  longitudinal 
stricB.  They  form  bright  red  rays,  contrasting  with  the  background  of  the 
mucosa,  which  is  paler  and  of  a  yellowish-red  colour. 

Lastly,  the  surface  of  a  normal  mucous  membrane  is  smooth  and  ghsten- 
ing  in  its  whole  extent.  Under  the  influence  of  disease  it  becomes  irregular 
and  dull. 

Normally  the  orifices  of  the  lacunae  of  Morgagni  are  hardly  visible. 
They  are  tiny  points,  somewhat  like  pin-pricks  which  have  not  closed,  and 
are  found  on  the  upper  surface.  Similarly,  the  glands  of  Littre  are  almost 
invisible  during  health.  Whilst  these  two  types  of  orifices  escape  notice 
under  normal  conditions,  they  become  prominent  and  congested  when 
affected  by  disease.  They  then  become  easily  visible,  and  their  recognition 
is  often  facilitated  by  a  red  zone  surrounding  them. 


EXPLANATOEY  TEXT  TO  PLATE  I 


Fig.  1. — NoBMAL  Aspect  of  the  Verumontanum. 

This  figure  gives  a  full  view  of  the  verumontanum  where  it  is  widest. 
The  prostatic  utriculus  is  not  visible.  In  the  upper  part  of  the 
figure  the  mucous  membrane  is  finely  folded,  bolster-like.  This 
anatomical  arrangement  is  a  valuable  landmark  for  a  correct 
appreciation  of  the  size  of  the  verumontanum  and  of  its  limits. 


Fig.  2. — Normal  Verumontanum  on  which  the  Orifices  of  the 
Ejaculatory  Ducts  are  Fab  Apart. 

There  is  no  median  utriculus  in  this  case.  Each  ejaciilatory  duct  opens 
separately  on  one  of  the  lateral  aspects  of  the  verumontanum. 
The  whole  presents  a  most  striking  appearance,  which  is  not  unlike 
that  of  a  diver's  helm_et. 


Fig.  3. — Normal  Aspect  of  the  Prostatic  Fossette,  which  is 
situated  between  the  Neck  of  the  Bladder  and  the  Veru- 
montanum. 

Below,  one  sees  the  dome  of  the  posterior  part  of  the  verumontanum. 
Above,  the  neck  of  the  bladder  is  visible,  from  which  well-marked 
longitudinal  folds  slope  downwards  in  a  fan-like  manner.  On 
either  side,  and  at  the  top  of  the  figure,  one  notices  the  origins  of 
the  bolster,  which  comes  to  lie  over  the  verumontanum,  and  is 
shown  in  Pigs.  1,  2,  and  4  in  its  full  extent. 


Fig.  4. — Normal  Aspect  of  the  Prostatic  Utriculus. 

This  figure  is  practically  the  same  as  Fig.  1,  but  it  differs  inasmuch 
as  the  orifice  of  the  prostatic  utriculus  is  visible  in  the  middle 
of  the  verumontanum.  Above,  the  bolster  is  again  shown ;  and 
below,  the  origin  of  the  urethral  crest  can  be  made  out. 


Fig.  5. — Normal  Aspect  of  the  Bulb  of  the  Urethra. 

The  central  figure  has  the  shape  of  a  vertical  slit.     The  aspect  of  this 
region  is  characteristic. 


Fig.  6. — Normal  Aspect  of  a  Large  Lacuna  of  Morgagni 
(Guerin's  Valve). 

The  lacuna  is  V-shaped,  the  pomt  of  the  V  being  directed  down- 
wards, and  forms  a  regular  pouch  in  the  mucous  membrane  of 
the  penile  urethra. 

To  fact  page  158. 


Georges  LUYS. 


Planclxe  I. 


FlQ.l 


Fid.  2 


Fi6  3. 


Fid.  4-. 


Fid. 5. 


'Imp .  L.  L  afontaine ,  Paris . 


F16.6. 


UKETHROSCOPY  159 

2,  Ueethroscopy  of  the  Normal  Anterior  Urethra. 

The  central  figure  shows  little  variation  in  the  anterior  urethra.  It 
assumes,  however,  the  aspect  of  a  vertical,  rounded-off  slit  in  the  glans. 
In  the  penile  portion  it  is  a  point,  but  widens  out  now  and  then,  taking  the 
form  of  a  transverse,  somewhat  jagged  fissure. 

The  longitudinal  folds  are  seen  to  radiate  like  the  spokes  of  a  wheel, 
except  in  the  region  of  the  glans,  where  the  mucous  membrane  is  smooth. 
Their  number  usually  varies  between  four  and  ten,  and  they  are  best  seen 
with  a  small  tube. 

The  longitudinal  striation  is  due  to  vascular  ramifications,  and  is  best 
observed  in  vigorous  subjects. 

The  lacunoB  of  Morgagni  open  along  the  upper  wall  of  the  urethra.  Their 
orifices  are  little  fossse,  which  do  not  differ  in  their  colour  from  the  surround- 
ing parts.  In  health  their  walls  are  flush  with  the  rest  of  the  mucous 
membrane. 

The  large  lacunae  are  easily  recognized,  when  they  are  examined  in  the 
parietal  position,  by  the  fact  that  they  form  a  V,  the  point  of  which  is 
directed  downwards  (Coloured  Plate  I.,  Fig.  5).  The  branches  of  the  V 
correspond  to  the  walls  of  the  pouch. 

Littre's  glands  are  found  in  large  numbers  all  over  the  surface  of  the 
urethral  mucous  membrane.  In  health  they  are  practically  invisible; 
they  only  become  prominent  when  they  are  inflamed. 

Cowper's  glands  open  into  the  urethra  by  two  orifices,  which  are  nearly 
always  concealed  by  the  folds  in  the  mucous  membrane. 

3.  Urethroscopy  of  the  Normal  Posterior  Urethra. 

When  the  endoscopic  tube  has  been  introduced  very  far,  one  can  tell 
if  it  has  entered  the  bladder  by  the  sudden  ease  with  which  the  instrument 
can  be  moved  to  and  fro,  and  by  the  fact  that  urine  escapes  when  the  pilot 
is  withdrawn.  The  tube  is  then  gently  retracted,  and  the  urethra  is  swabbed 
dry. 

When  the  urine  ceases  to  flow,  and  the  swabs  are  no  longer  moistened, 
one  may  be  certain  that  the  far  end  of  the  instrument  is  outside  the  bladder. 

One  now  attaches  the  handle  and  the  lamp,  and  turns  them  into  their 
proper  position  {vide  p.  154). 

One  then  sees  a  characteristic  picture  of  this  region,  which  is  represented 
in  the  Coloured  Plate  I.  and  in  Fig.  108.  At  the  top  one  sees  an  infundib- 
ulum— the  neck  of  the  bladder.  From  it  descend  the  folds  of  the  mucous 
membrane  as  regular  and  divergent  lines.  They  imitate  a  fan,  the  wide 
portion  being  below,  and  its  handle  above. 


160  GONORRHEA 

If  one  withdraws  slightly  the  endoscopic  tube,  the  posterior  extremity 
of  the  verumontanum  comes  into  view.  Just  behind  this  hindmost  part  of 
the  verumontanum  is  a  small  depression  which  should  be  thoroughly 
examined.  This  "  prostatic  fossette  "  is  very  often  affected  in  chronic 
urethritis.  It  is  frequently  the  seat  of  an  inflammation  which  cannot  be 
discovered  by  any  other  means.  Fig.  108  shows  its  limits.  In  front  it  ex- 
tends as  far  as  the  posterior  border  of  the  verumontanum,  and  behind  as  far 
as  the  neck  of  the  bladder. 

It  has  been  said  that  this  structure  could  not  be  explored  properly 
through  a  straight  tube.  This  statement  is  inaccurate,  for  it  is  sufficient 
to  press  the  end  of  the  urethroscope  down  slightly  by  raising  the  handle. 
The  bulk  of  the  verumontanum  is  then  out  of  the  way,  and  a  most 
complete  view  of  its  posterior  end  is  obtained. 


Pig.  108. — Uretheoscopic  View  of  the  "  Prostatic  Fossette." 

Normal  aspect  of  the  part  of  tlie  posterior  urethra  which  is  limited  below  by  the 
verumontanum,  and  above  by  the  neck  of  the  bladder. 

These  structures  having  been  examined,  one  continues  to  withdraw  the 
endoscopic  tube  farther  and  farther.  The  body  of  the  verumontanum  then 
comes  into  view ;  it  resembles  an  elongated  spindle,  and  is  represented  in 
Plate  I.  The  three  figures  (1°,  2°,  3°)  in  the  plate  show  its  most  common 
aspects.  Sometimes  it  can  be  seen  in  its  middle  part  as  a  smooth  rounded 
eminence  which  occupies  nearly  the  whole  lumen  of  the  tube ;  in  other  cases 
one  can  only  see  the  anterior  part  when  the  tube  has  been  withdrawn  farther. 
The  prominence  of  the  verumontanum  is  then  much  less  both  in  height  and 
in  width,  and  is  continuous  in  front  with  the  urethral  crest. 

As  a  rule  the  utriculus  is  not  visible.  Occasionally,  however,  it  is  quite 
distinct,  as  the  coloured  plate  shows. 

In  most  cases  it  is  single  and  occupies  the  middle  line.  It  is,  however, 
not  infrequently  double.     Each  sinus  then  corresponds  to  the  opening  of 


URETHROSCOPY 


161 


an  ejaculatory  duct,  and  is  situated  to  one  side  of  the  middle  line.  The 
whole  verumontanum  has  then  a  most  striking  resemblance  to  a  diver's 
helmzt  {vide  Chapter  IX.,  Catheterization  of  the  Ejaculatory  Ducts). 

Urethroscopic  examination  of  the  verumontanum  is  of  considerable 
importance,  because  this  structure  is  always  involved  when  the  seminal 
vesicles  are  diseased,  so  much  so  that  one  has  a  right  to  call  the  utriculus 
"  the  mirror  of  the  seminal  vesicles." 

Above  the  verumontanum  the  urethral  mucous  membrane  is  thrown 
in  delicate  folds,  forming  a  kind  of  crescent-shaped  bolster.     This  aspect  is 


5  D. 


Fig.  109. — ^Normal  Aspect  of  the  "  Prostatic  Fossetie  "  between  the  Postesior 
End  of  the  Verumontanum  an^d  the  Neck  of  the  Bladder. 


characteristic.  The  concavity  of  this  crescent  is  directed  downwards,  and 
thus  this  bolster,  which  occupies  the  upper  part  of  the  urethroscopic  tube, 
forms  a  kind  of  frame  for  the  verumontanum.  It  is  an  important  landmark 
for  a  correct  appreciation  of  the  shape  and  the  limits  of  the  verumontanum. 
In  front  of  it,  the  urethroscopic  picture  changes  completely.  The 
anterior  extremity  of  the  verumontanum  becomes  more  and  more  pointed, 
forming  the  urethral  crest,  and  finally  disappears  completely.  The  bolster 
which  filled  the  upper  part  of  the  lumen  of  the  tube  increases  until  a  regular 
figure  is  formed  which  is  characteristic  of  the  membranous  portion. 

11 


162  GONORKHEA 

Diagrammatically,  this  portion  of  the  urethra  is  composed  of  a  central 
point,  representing  the  lumen  of  the  membranous  urethra,  and  folds  which 
radiate  from  it  in  all  directions.  The  latter  correspond  to  the  spokes  of  a 
wheel,  whilst  the  lumen  represents  the  hub. 

As  long  as  the  tube  is  in  the  membranous  portion,  it  is  gripped  firmly; 
it  becomes  freer  once  it  leaves  this  portion. 

When  the  tube  is  on  the  point  of  leaving  the  posterior  urethra,  the  handle 
of  the  urethroscope  should  be  raised.  Omission  of  this  little  precaution  is 
only  too  readily  followed  by  a  sudden  spontaneous  correction  of  the  position 
of  the  instrument.     This  unexpected  readjustment  is  likely  to  give  the 


Fig.  110. — Normal  Verumontanum  ON        Fig.    111. — Normal  Verxtmontantim 

WHICH  THE  UtRICULUS  IS  NOT  VISIBLE.  WITH   A  VISIBLE  SiNGLE  UtrICULUS. 

patient  pain,  and  should  be  avoided.  The  operator,  who  has  been  in  the 
position  shown  in  Fig.  101,  assumes  the  one  shown  in  Fig.  102. 

The  urethroscopic  picture  now  changes  completely.  The  present  region, 
the  bulb,  is  characterized  by  a  long,  well-marked  vertical  slit.  This  lateral 
compression  of  the  central  figure  is  due  to  the  bulbo-  and  ischio-cavernosi 
muscles  present  at  this  level.  On  either  side,  the  mucous  membrane  shows 
well-marked  folds  where  it  covers  these  muscular  swellings. 

The  urethroscopic  aspect  of  the  bulb  is  a  kind  of  miniature  of  the  inter- 
gluteal  fold. 

4.  Urethroscopy  of  the  Anterior  Urethra  in  Disease. 

General  Remarks. — The  lesions  of  chronic  urethritis  as  they  appear 
under  the  urethroscope  have  been  described  in  a  masterly  fashion  by 
Oberlander  in  1893,  and  again  by  him  in  1910  in  collaboartion  with  KoU- 
mann.^    Further  valuable  contributions  to  this  study  have  been  made  by 

^  Oberlander  and  KoUmann,  loc.  cit. 


URETHROSCOPY  163 

Keersmaecker  and  Verhoogen,^  Wossidlo,^  and  in  France  by  Janet''  and 
Fraisse."* 

In  harmony  with  Oberlander,  we  distinguish  two  distinct  types  of  chronic 
inflammatory  lesions  in  chronic  urethritis. 

The  first  is  the  soft  infiltration,  which  is  characterized  macroscopically  by 
a  swelling  of  the  mucous  membrane,  and  microscopically  by  an  infiltration 
of  the  submucosa  with  small  embryonic  cells,  the  whole  process  being 
accompanied  by  vascular  dilatation. 

The  second  one,  which  follows  upon  the  former  in  the  evolution  of  the 
morbid  process,  is  the  hard  infiltration.  Here  the  mucous  membrane  is 
especially  pale,  and  of  a  greyish-yellow  colour.  The  histological  examina- 
tion shows  the  submucosa  to  be  invaded  by  connective  fibrillse  which 
gradually  take  the  place  of  the  embryonic  cells  found  in  the  soft  variety, 
and  convert  the  submucosa  step  by  step  into  fibrous  tissue.  This  fibrous 
tissue  interferes  with  the  circulation  by  strangulating  the  bloodvessels — 
hence  the  characteristic  pallor  of  the  urethral  mucous  membrane. 

In  its  slightest  degree,  this  hard  variety  corresponds  to  Ofcis's  wide 
strictures,  whilst  its  more  advanced  forms  represent  the  strictures  in  the 
usual  sense. 

The  soft  infiltration  follows  upon,  and  even  accompanies,  the  inflam- 
matory lesions  of  acute  urethritis.  It  is  chiefly  found  in  the  first  stages  of 
chronic  urethritis.  It  is  subsequently  replaced  by  hard  infiltration  as  the 
disease  progresses. 

Although  these  two  varieties  of  lesions  are  distinct  urethroscopicaUy  and 
histologically,  they  are  merely  successive  phases  of  one  and  the  same  morbid 
process.     Moreover,  they  often  exist  in  the  same  urethra  at  the  same  time. 

Chronic  urethritis  is  characterized  by  its  localized  chronic  inflammatory 
lesions.  Every  one  of  the  diseased  areas  may  take  a  course  of  its  own,  and 
independently  of  the  other  lesions  present.  Thus,  in  a  given  urethra  one 
may  find  in  alternation  healthy  mucosa,  soft  infiltrations,  and  hard  infiltra- 
tions. 

The  distinction  between  hard  and  soft  infiltrations  is  convenient  and 
practical  for  descriptive  purposes.  One  should,  however,  not  gain  the  im- 
pression that  they  are  absolutely  distinct  morbid  entities,  and  that  one 
urethra  suffers  from  hard  infiltration,  and  another  from  the  soft  variety. 
As  a  rule  both  types  of  lesion  are  present  at  the  same  time. 

We  will  now  examine  these  different  varieties  and  their  relation  to  the 
anterior  and  the  posterior  urethra. 

^  Keersmaecker  and.  Verhoogen,  loc.  cit. 
^  Wossidlo,  loc.  cit. 

^  Janet,  Ann.  des  Hal.  des  Organes  Ginito-Urin.,  1891 ;  "Endoscopie  Uretrale"  in 
Legons  Cliniques  de  Guyon,  Paris,  1903. 

*  Fraisse,  Gonorrhee  Chronique  de  V Homme,  Paris  (Maloine),  1910. 


164  GONOREHEA 

The  commonest  sites  for  the  lesions  of  chronic  urethritis  are — the  middle 
of  the  penile  portion,  especially  the  peno-scrotal  angle,  and  the  membranous 
region.     Very  often  several  different  places  are  affected  simultaneously. 

Soft  Infiltration. — A  urethra  which  presents  only  soft  infiltrative  lesions, 
opposes  no  resistance  to  the  passing  of  an  endoscopic  tube.  The  worst  that 
can  happen  is  slight  bleeding  when  the  instrument  is  being  introduced,  or 
when  one  dries  the  mucosa  with  swabs. 

The  general  aspect  of  a  mucous  membrane  which  is  affected  with  soft 
infiltration  is  that  of  an  inflamed,  hyperemic,  and  swollen  mucous  surface. 
It  is  usually  smooth  and  shiny  {vide  Plate  II.),  and  is  not  unlike  a  mass  of 
hemorrhoids. 

The  colour  varies  from  a  dark  pink  to  a  blood  red  or  bluish  red. 

The  seat  of  the  soft  infiltrations  is  most  often  in  the  prostatic  and  mem- 
branous portions.  The  lesions  are  present  as  localized  irregularly  dis- 
seminated patches. 

Their  size  is  variable.  Sometimes  they  are  small  semicircles;  on  other 
occasions  they  are  big  patches  extending  over  an  area  of  several  centi- 
metres. 

Their  number  is  also  subject  to  variations.  In  some  cases  only  one 
soft  infiltration  is  present,  but  as  a  rule  several  lesions  are  found,  which 
are  separated  from  each  other  by  areas  of  healthy  tissue. 

Their  shape  is  irregular ;  their  borders  are  ill-defined,  and  gradually  merge 
into  the  neighbouring  healthy  parts. 

In  the  beginning,  the  epithelium  has  its  lustre ;  but  when  the  lesions  are  of 
some  standing,  desquamation  takes  place,  and  it  becomes  thinner  and  more 
friable.  Its  polish  disappears,  and  it  becomes  rough  and  opaque.  It  tends 
to  become  deficient  in  places ;  the  exposed  papillary  layer  then  proliferates, 
and  forms  small  granulations  which  are  analogous  to  those  found  in  skin 
wounds.  They  are,  however,  less  pronounced,  and  are  visible  as  small 
reddish  spots  of  irregular  outline.  They  have  a  bright  red  surface,  and 
bleed  easily.     They  are  very  common  about  the  bulb. 

The  longitudinal  folds  of  the  mucous  membrane  are  effaced  to  a  con- 
siderable extent.  Instead  of  the  great  number  present  in  health,  one  only 
sees  two  or  three  ill-defined  lines  which  project  into  the  lumen  of  the 
passage,  and  may  even  obliterate  the  central  figure. 

The  longitudinal  striation  becomes  almost  invisible  owing  to  the  swelling 
and  hyperemia  of  the  mucosa,  which  shows  a  uniform  smooth  surface. 

The  central  figure  is  nearly  always  effaced.  It  no  longer  gapes,  and  no 
cavity  is  visible,  not  even  if  one  withdraws  the  tube. 

The  lacunce  of  Morgagni  and  the  glands  of  Littre  are  always  affected  in 
soft  infiltration.  Their  irritation  is  followed  at  first  by  an  increase  in  their 
secretion.     The  mucosa  which  covers  them  is  red  and  somewhat  puffy. 


URETHROSCOPY  165 

Their  excretory  ducts  appear  as  little  red  projections  of  tlie  size  of  a  pin's 
head,  with  raised  and  glassy  borders.  A  mucous  or  purulent  discharge  is 
seen  to  issue  from  them.  Professor  Kollmann  has  devised  a  special  pipette 
for  aspirating  their  secretions  for  microscopical  examination. 

The  lacunse  of  Morgagni  form  on  the  surface  of  the  mucous  membrane 
projections  which  may  reach  the  size  of  a  small  pea.  Very  often  they  appear 
as  red  nodules  of  the  size  of  a  pin's  head.  Their  orifice  may  be  visible  on 
the  top  or  on  the  side  of  the  swelling.  The  borders  are  congested  and 
translucent,  and  from  the  orifice  a  mucous  or  a  purulent  secretion  is 
discharged. 

In  the  posterior  urethra  the  verumontanum  is  dark  red,  swollen,  and 
enlarged,  when  it  is  the  seat  of  a  soft  infiltration.  The  orifice  of  the  utriculus 
is  inflamed,  gapes,  and  yields  a  mucous  or  purulent  discharge.  Very  often 
the  swelling  of  the  verumontanum,  which  becomes  perfectly  smooth,  is  so 
marked  that  the  utriculus  and  the  orifices  of  the  ejaculatory  ducts  disappear 
in  the  substance  of  the  mucous  membrane,  and  are  concealed  from  view. 


Fig.  112. — Kollmann's  Pipette  for  aspikating  Glandular  Secretions 
FROM  THE  Urethra. 

When  these  openings  are  visible,  they  are,  as  well  as  those  of  the  prostatic 
glandules,  red  and  swollen,  and  surrounded  by  a  sharply  projecting  border. 

In  some  cases  one  can  see  on  its  lateral  walls  the  ejaculatory  ducts, 
which  are  filled  to  a  greater  or  lesser  extent  with  pus.  In  one  of  my  patients, 
for  instance,  who  was  sufiering  from  a  left  gonorrheal  epididymo-orchitis, 
I  saw  with  the  greatest  ease  that  the  left  ejaculatory  duct  discharged  pus, 
and  that  it  was  surmounted  by  a  highly  congested  and  deviated  veru- 
montanum. 

The  congested  membranous  region  often  appears  cyanosed  and  loses 
its  lustre.  Its  folds  become  coarser  and  swollen,  and  the  mucous  membrane 
bulges,  or  even  prolapses,  into  the  lumen  of  the  urethroscope. 

Pa'pillomata  often  accompany  soft  infiltrations.  Sometimes  they  are 
small  and  isolated;  on  other  occasions  they  are  long,  slender,  and  fragile, 
or  they  may  be  short  and  thick,  and  project  into  the  lumen  of  the  urethro- 
scopic  tube. 

These  papillomata  are  nearly  always  similar  to  those  found  on  the 


166 


GONORRHEA 


prepuce.     They  are  due  to  an  excessive  proliferation  of  the  chorion  at  the 
point  where  the  desquamation  of  the  epithehum  has  exposed  the  papillae. 

Occasionally  they  form  little  agglomerations,  and  they  may  reach  such 
a  size  that  they  obstruct  the  canal.  They  are  most  common  in  the  regions 
of  the  bulb  and  of  the  verumontanum.  Oberlander  has  met  with  a  case  in 
which  they  extended  all  along  the  urethra  into  the  bladder.  Griinfeld  has 
pubhshed  numerous  examples  in  his  work  on  endoscopy.^  I  have  shown 
several  in  the  coloured  plates  of  this  book  {vide  Plate  II.). 

In  a  patient,  aged  twenty -six — sent  to  me  by  Professor  Henri  Hartmann — who  had 
been  suffering  from  a  gleet  for  two  and  a  half  years,  the  urethroscope  allowed  me 
to  discover  on  the  upper  wall  of  the  penile  portion,  near  the  root  of  the  penis,  a 

large  lacuna,  which  was  reduced  to  two  loose  flaps.  At 
the  bottom  of  the  lacuna  was  a  small  polypus  close  to 
the  insertion  of  the  flaps  (Fig.  113). 

Hard  Infiltration. —  Unlike  the  soft  variety, 
which  does  not  interfere  with  the  passing  of  a 
tube,  the  hard  infiltrations  always  oppose  a  certain 
resistance  to  the  introduction  of  an  instrument. 
The  difficulty  depends  on  the  degree  of  the  in- 
filtration, and  is  sometimes  so  considerable  that 
even  the  smallest  urethroscopic  tube  cannot  pass. 
One  is  then  confronted  with  a  tight  stricture. 
Absence  of  suppleness  is  the  characteristic  feature  of  all  hard  infiltrations. 
It  is  the  result  of  sclerosis.  The  small  infiltration  cells  are  gradually  replaced 
by  connective  tissue,  and  as  the  latter  becomes  more  dense  and  firmer,  the 
circulation  is  interfered  with.  The  mucosa  thus  loses  its  colour  and  its 
elasticity,  and  ultimately  it  is  converted  into  a  tough  and  rigid  tissue. 

When  the  mucous  membrane  has  undergone  hard  infiltration  (vide 
Plate  II.),  it  becomes  pale  and  anemic.  In  mild  cases  its  colour  is  less  bright 
than  normally;  in  more  advanced  ones  it  becomes  whitish-grey  or  yellowish. 
Confirmed  strictures  are  of  a  uniform  whitish-grey  tint.  These  colour 
changes  depend  upon  the  more  or  less  active  formation  of  fibrous  tissue, 
which  gradually  destroys  the  circulation. 

This  strangulation  of  the  bloodvessels  by  fibrous  tissue  is  the  cause  of 
the  pale,  greyish  and  mortified  aspect  of  genuine  strictures,  which  require  a 
course  of  dilatation  treatment  before  they  can  be  urethroscoped. 

The  seat  of  these  lesions  is  most  often  found  in  the  middle  part  of  the 
penile  urethra,  at  the  peno-scrotal  angle,  and  in  the  membranous  portion. 
The  lesions  are  disseminated  as  localized  patches.  Histologically,  the 
fibrosis  is  most  marked  around  the  glands  of  the  urethra,  but  it  is  also  found, 


Fig.  113. — Diagram  op 
THE  Lesion  SHowiir 
IN  Plate  II.,  Fig.  5. 


1  Griinfeld, 
Lief.  51. 


Die  Endoskopie  der  Harnrohre  und    Blase,"  Deutsch.  Chir.,  1881, 


URETHROSCOPY  167 

although  less  often,  within  the  sub3tance  of  the  mucosa.  Small  cicatrices 
about  1  to  2  centimetres  long,  or  small  stellate  scars  of  1  to  2  millimetres, 
are  then  prezent. 

Measuring  Hard  Infiltrations. — It  is  extremely  difficult,  if  not  impossible, 
to  giuge  the  exact  extent  of  any  hard  infiltration,  because  the  process 
varies  in  intensity. 

Oberlander  recognizes  three  degrees : 

In  the  first  the  lumen  of  the  urethra  retains  its  normal  width. 

In  the  second  the  lumen  is  constricted,  but  it  still  admits  a  tube  No.  23. 

In  the  third  the  infiltration  is  so  advanced  that  this  instrument  cannot 
pass. 

This  classification  is  obviously  arbitrary,  but  it  is  practical  and  useful. 

A  simpler  but  less  accurate  classification  would  consist  in  recognizing  two 
kinds  only — the  mild  forms,  which  correspond  to  Ofcis's  "  wide  strictures  "  ; 
and  the  advanced  forms,  comprising  the  strictures  in  the  general  sense. 

In  practice  one  meets  with  so  many  intermediate  forms  that  a  sharp 
distinction  between  the  mild  and -advanced  types  cannot  always  be  made. 

The  pathological  changes  in  the  ejnthelium  are  due  to  a  deficient  nutrition. 

In  the  first  stage  the  epithelium  loses  its  lustre  and  its  normal  trans- 
parency, and  becomes  dull.  When  the  lesions  are  more  accentuated,  pro- 
liferation of  epithelial  cells  and  desquamation  take  place.  These  phenom- 
ena are  chiefly  noticeable  at  the  points  where  the  disease  is  most  pronounced. 
The  epithelial  surface  is  then  covered  irregularly  with  little  lumps;  small 
projections  about  1  millimetre  high  are  visible,  and  next  to  them  one  finds 
a  loss  of  substance — more  or  less  extensive  raw  patches,  which  bleed  readily. 
The  epithelial  proliferation  gives  rise  to  small  areas  which  are  usually 
round  and  of  a  pearl-grey  colour.  In  some  cases  they  are  minute,  no  bigger 
than  a  pin's  head,  and  hardly  distinguishable  from  the  neighbouring  mucosa ; 
whilst  in  other  instances  they  are  several  millimetres  thick,  1  centimetre 
long,  and  very  different  in  their  aspect  from  the  neighbouring  tissues. 

Instead  of  forming  these  little  islands,  the  epithelial  proliferation  may 
extend  over  a  huge  portion  of  the  urethra.  A  horny  change  then  takes 
place  in  the  urethral  epithelium;  it  becomes  thick  and  keratinized — fachy- 
dermia  or  leucoplasia. 

The  mucosa  is  dull  and  greyish  in  this  condition,  and  only  shows  its 
normal  pink  colour  here  and  there.  It  is  as  if  the  mucous  membrane  were 
covered  by  a  thick  layer  of  dust. 

Urethral  leucoplasia  is  most  often  locahzed  in  the  shape  of  patches  of 
variable  size,  which  are  brilliant  white,  or  yellowish  white,  or  greyish  in 
colour,  and  present  a  typical  aspect.  Their  surface  is  granular  or  wrinkled, 
instead  of  being  smooth.  Their  outline  is  oval,  and  their  long  axis 
follows  that  of  the  urethra.     These  patches  are  adherent;  it  is  impossible 


168  GONORRHEA 

to  rub  tliem  ofi  witli  a  swab ;  however,  with  a  certain  amount  of  energy  one 
can  manage  to  detach  a  small  piece.  The  underlying  mucous  membrane 
is  then  found  to  be  dark  red,  rough,  and  dull,  but  it  does  not  bleed  easily. 

The  longitudinal  folds  of  the  mucous  membrane  diminish  considerably 
in  hard  infiltration,  and  even  tend  to  disappear  completely  in  the  advanced 
cases  which  terminate  in  the  formation  of  tight  strictures.  The  urethro- 
scopic  appearance  of  the  passage  is  that  of  a  rigid  tube,  which  continues  to 
gape  after  the  instrument  is  withdrawn.  It  is  composed  of  an  inelastic 
tissue  with  uniformly  stiff  walls. 

The  central  fijure  nearly  always  resembles  an  elongated  funnel  with  rigid 
walls.  In  cases  of  stricture  this  funnel  may  easily  measure  1  to  2  centi- 
metres. The  picture  then  seen  is  absolutely  typical.  The  urethral  walls 
are  kept  in  position  by  the  fibrous  tissue  which  surrounds  them,  and  fail 
to  meet.  They  form  a  regular  tunnel  or  funnel  with  pale  and  foldless 
walls  which  have  the  same  consistency  as  cardboard. 

Fig.  2  on  Plate  II.  shows  a  characteristic  hard  infiltration.  The  card- 
board-like walls  of  the  urethra  are  seen  to  gape  widely. 

Lesions  of  the  Lacunae  and  of  the  Glands. — The  lacunae  of  Morgagni  and 
the  glands  of  Littre  are  always  affected  to  some  extent  when  hard  infiltra- 
tions are  present.     With  Oberlander  we  distinguish  two  different  types. 

If  the  gland  duct  remains  pervious,  the  gland  can  discharge  its  contents. 
This  is  the  glandular  variety.  Or  the  duct  may  be  obliterated,  either  by 
compression  due  to  the  surrounding  structures  or  by  the  contraction  of  its 
own  walls.  The  secretion  is  then  pent  up,  and  accumulates  within  the  gland, 
which  is  converted  into  a  cyst.  This  is  the  follicular  or  dry  form.  The  term 
"  dry  "  is  here  only  used  owing  to  the  aspect  of  the  mucous  membrane  after 
it  has  been  deprived  of  its  glands.  A  more  or  less  purulent  and  persistent 
discharge  nearly  always  accompanies  this  condition. 

(a)  In  the  glandular  type  the  orifices  of  Littre's  glands  are  enlarged, 
and  surrounded  by  an  inflammatory  ring.  These  openings  are  like  craters, 
and  frequently  give  issue  to  a  Hquid  secretion.  Very  often  slight  pressure 
with  the  end  of  the  endoscopic  tube  causes  the  glandular  orifices  to  gape, 
and  to  discharge  a  clear  or  a  purulent  fluid,  as  the  case  may  be.  In  some 
instances  these  openings  become  enormous,  and  flood  the  urethroscopic 
tube  with  their  products  when  it  presses  on  them. 

Morgagni's  lacunae  show  similar  changes  {vide  Plate  III.,  Fig.  4).  The 
edges  of  their  orifices  become  crater-like,  and  yield  a  mucous  or  a  purulent 
discharge.  If  the  perilacunar  infiltration  predominates,  the  excretory 
channels  project  beyond  the  level  of  the  mucous  membrane  as  little  red 
bosses. 

In  patients  who  have  been  dilated  a  few  times,  the  enlarged  lacunar  and 
glandular  orifices  sometimes  burst,  and  their  walls  fissure. 


EXPLANATORY  TEXT  TO  PLATE  II 


Fig.   1. — Typical  Urethroscopio  Image  of  a  Soft  Infiltration 

AJFFECTING   THE   BuLBOUS   PORTION   OF   THE  UrBTHRA. 

The  mucosa  forms  puffy  and  oozing  masses  which  are  not  unlike  a 
bunch  of  hemorrhoids. 


Fig.  2. — Urethroscopic  Aspect  of  a  Urethral  Stricture. 

The  walls  of  the  urethra  are  invaded  by  fibrous  tissue,  and  present 
the  appearance  of  cardboard.  The  mucous  membrane  is  abnor- 
mally pale,  and  the  central  figure  is  enormous  owing  to  the 
rigidity  of  the  urethral  walls.  As  the  latter  cannot  meet,  and  as 
the  intensity  of  the  fibrosis  varies  in  difierent  places,  an  irregular 
tunnel  is  formed  with  asymmetrical  walls.  In  places  encysted 
purulent  glands  of  Littre  are  visible. 


Fig.  3. — Phallus- shaped  Polypus  arising  from  the  Upper 
Aspect  of  the  Verumontanum. 


Fig.  4. — Lesions  of  the  Prostatic  Fossette  Behind  the 
Verumontanum. 

(This  figure  should  be  compared  with  Fig.  3  on  Plate  I.)  Below,  an 
elevation,  the  posterior  end  of  the  verumonta,num,  is  visible. 
Above,  one  notices,  instead  of  a  well-folded  and  regular  mucous 
surface,  a  number  of  small  abscesses  and  muco-purulent  masses 
in  which  the  organisms  find  shelter  for  a  considerable  time. 
Lesions  of  this  kind  are  relatively  common  in  chronic  gonorrhea, 
and  cannot  be  diagnosed  by  any  other  method  than  urethroscopy. 
The  condition  shown  in  this  figure,  which  is  original,  cannot  be 
seen  with  instruments  fitted  with  an  optic  portion  which  conceals 
the  upper  part  of  the  prostatic  fossette. 


Fig.  5. — Extraordinary  Aspect  of  the  Ejaculatory  Duct. 

This  figure  refers  to  the  case  described  on  p.  177,  in  which  constant 
recurrences  due  to  the  gonococcus  were  only  checked  after  the 
verumontanum  had  been  cauterized.  It  was  found  necessary  to 
destroy  this  structure  Math  the  cautery,  and  thus  the  ejaculatory 
ducts  were  exposed.  They  are  seen  in  apposition  like  the  barrels 
of  a  gun. 


Fig.  6. — Small  Polypus  situated  on  the  Top  of  the 
Verumontanum. 

The  clinical  history  of  this  case  is  described  on  p.  176. 


To  face  page  16S. 


Georges  LUYS 


Planchell. 


FlQ.l. 


F16.Z 


F16.  3, 


F16.4. 


Fid. 5. 


Imp  .LI  af  ontaiue  ,Paris . 


K6.6. 


URETHROSCOPY  169 

This  phenomenon  explains  the  exacerbations  which  are  frequently  noted 
after  the  first  dilatations. 

One,  for  instance,  meets  with  cases  like  the  following : 

A  patient  comes  who  has  very  little  discharge,  often  only  a  morning- 
drop.  The  urine  is  clear,  including  the  specimen  in  the  first  glass.  As  he 
ha3  no  pain,  and  as  there  appears  to  be  no  other  contra-indication,  one 
explores  his  urethra  with  an  olive,  and  then  with  some  metal  instruments, 
in  order  to  discover  any  patch  of  infiltration  which  may  be  present.  Two 
days  later  the  patient  returns ;  he  is  very  angry,  and  has  a  profuse  discharge 
which  is  full  of  gonococci.  Under  circumstances  of  this  kind  the  patient  is 
only  too  apt  to  blame  his  surgeon,  and  he  may  even  accuse  him  of  having 
contaminated  him  by  using  a  dirty  instrument.  As  a  matter  of  fact,  the 
explanation  of  this  occurrence  is  very  simple  for  those  who  are  familiar 
with  urethroscopic  work. 

One  can  often  see  by  means  of  the  endoscope  glands  of  Littre  and 
lacunae  of  Morgagni  which  are  represented  by  small  thin- walled  cysts. 
These  little  cysts  often  contain  gonococci,  and  as  long  as  their  walls  remain 
intact,  the  organisms  are  imprisoned  within  them.  The  introduction  of  a 
stout  metal  instrument  into  the  urethra  very  easily  breaks  their  walls.  The 
cocci  are  then  set  free,  and  reinfect  the  mucous  membrane. 

(6)  In  the  dry  or  follicular  form  the  pressure  of  the  invading  fibrous 
tissue  occludes  the  glands  and  their  ducts.  They  thus  become  converted 
into  subepithelial  cystic  cavities  containing  colloid  matter. 

Occasionally  these  glands  are  transformed  into  small  purulent  cysts 
which  may  be  found  isolated  or  in  groups  [vide  Plate  III.). 

Figs.  1  and  2  on  Plate  III.  show  the  condition  found  in  a  sergeant-major, 
aged  twenty-five,  who  was  stationed  in  Paris.  He  had  been  discharging  for  fifteen 
months,  and  showed  no  improvement  under  a  treatment  consisting  of  irrigations  and 
instillations.  Clinically,  nothing  but  an  insignificant  discharge  was  found.  The 
urine  was  clear,  and  contained  only  a  few  filaments  in  the  first  glass.  An  olive  No.  21 
could  be  passed  without  any  difficulty.  The  urethroscopic  examination  of  the  penile 
portion  showed  a  great  number  of  small  white  purulent  spots,  which  imparted  a  granular 
appearance  to  the  micous  membrane.  Each  one  of  them  represented  an  inflamed 
gland  of  Littre  with  purulent  contents. 

As  they  were  very  numerous,  there  could  be  no  question  of  treating  them  individu- 
ally. I  therefore  decided  to  deal  with  them  en  bloc.  Dilatation  with  KoUmann's 
straight  instrument  was  resorted  to,  and  the  urethra  was  widely  dilated.  After  two 
months  a  considerable  improvement  was  obtained,  but  not  a  cure. 

I  therefore  urethroscoped  the  patient  again,  and  made  the  following  interesting 
discovery :  All  the  small  purulent  cysts  had  completely  disappeared  from  the  penile 
urethra,  which  had  been  well  dilated.  The  mucous  membrane  was  here  normal.  The 
portion  near  the  meatus,  however,  which  had  not  been  dilated,  still  contained  purulent 
cysts.  It  was  thus  clear  why  a  marked  improvement  had  taken  place,  and  why  the 
patient  was  not  cured.  The  remaining  diseased  points  were  now  dilated,  with  the 
result  that  their  mucous  surfaces  became  normal  again,  and  that  a  complete  cure  was 
obtained. 


170  GONORRHEA 

These  cysts,  of  which  a  typical  example  is  shown  in  Fig.  5  on  Plate  III., 
occasionally  reach  a  considerable  size  and  project  into  the  lumen  of  the 
urethra.  In  some  cases  they  burst  under  one's  very  eye  when  one  presses 
the  edge  of  the  tube  against  them,  and  flood  the  tube. 

This  has  happened  to  me  on  several  occasions.  One  of  the  best  examples 
of  this  kind  was  a  patient  who  was  sent  to  me  by  Dr.  Cheurlot.  A  young 
man  of  twenty-six,  who  had  been  suffering  from  a  chronic  urethritis  for 
something  like  eighteen  months,  presented  a  number  of  cysts  all  along  his 
penile  urethra.  Methodical  dilatation  led  to  a  complete  disappearance  of 
these  lesions,  and  cured  the  patient. 

Another  still  more  instructive  case,  in  which  Littre's  glands  were  con- 
verted into  cysts  in  the  same  way  as  in  the  case  shown  on  Plate  III.,  Fig.  5, 
is  the  following : 

A  youth  of  twenty-five  had  had.  a  discharge  for  eleven  months.  The  microscope 
showed  nothing  but  leucocytes  and  epithelial  cells.  The  urine  was  clear,  but  there 
were  heavy  filaments  in  the  first  glass.  The  urethra  admitted  an  olive  No.  20  readily, 
although  there  was  some  spasm  about  the  membranous  sphincter.  A  series  of  silver 
nitrate  instillations  gave  no  appreciable  result.  The  anterior  urethra  was  now  endo- 
scoped,  and  in  the  middle  of  the  penile  portion  several  glands  of  Littre  were  found  to  be 
enlarged  and  to  project  into  the  lumen  of  the  tube.  Most  of  them  appeared  to  be 
covered  with  a  thin  whitish  skin.  One  of  them  was  especially  prominent,  and  had  the 
features  of  a  cyst  of  considerable  size,  as  shown  in  the  plate. 

Methodical  and  gradual  dilatation  was  carried  out  by  means  of  KoUmann's  straight 
dilator.  At  the  end  of  three  months,  which  were  uneventful.  No.  44  G  was  reached, 
and  the  patient  was  freed  from  his  discharge.  The  urine  contained  no  longer  any 
filaments,  and  a  fresh  urethroscopic  examination  showed  that  there  was  nothing 
resembling  a  cyst  left  in  the  penile  urethra,  which  presented  a  normal  mucous  surface. 

Cases  of  the  follicular  or  dry  variety  are  common  in  which  the  ducts  of 
Littre's  glands  are  obliterated,  and  the  glands  themselves  are  visible  under 
the  urethroscope  as  appreciable  swellings  under  the  mucosa. 

One,  however,  also  meets  with  cases  in  which  the  proliferation  of  the 
urethral  epithelium  and  the  connective-tissue  infiltration  are  so  considerable 
on  the  surface  that  the  glands  are  pushed  downwards  below  the  level  of 
the  mucous  membrane.  This  type  of  lesion  is  much  more  troublesome, 
and  resists  treatment  to  an  extent  which  renders  a  cure  difficult,  although 
the  palpation  of  the  urethra  on  a  metal  sound  allows  one  to  diagnose  these 
lesions  easily  and  accurately. 

Urethral  palpation  {vide  Chapter  VII.)  often  reveals  the  presence  of  very 
definite  nodules  in  the  lower  wall  of  the  urethra.  They  are  usually  separate, 
and  of  the  size  of  a  millet-grain  or  hempseed.  Occasionally,  however,  they 
are  much  larger — as  big  as  a  hazelnut  or  a  walnut — and  they  may  open 
externally  and  lead  to  the  formation  of  a  urinary  fistula. 

When  one  has  located  one  of  these  swellings  by  palpation,  and  then 
examines  the  spot  with  the  urethroscope,  one  often  finds,  to  one's  astonish- 


URETHROSCOPY  171 

ment,  absolutely  nothing  except  a  smooth  mucous  surface.  Even  when 
one  inclines  the  endoscopic  tube  one  sees  nothing  further.  In  cases  of  this 
kind  the  gland  is  completely  shut  off,  and  has  no  longer  any  communication 
with  the  lumen  of  the  urethra.  A  typical  example  of  this  condition  is  the 
following  instance  : 

A  young  assistant  in  the  Paris  hospitals  had  contracted  gonorrhea,  for  which  he 
had  been  treated  for  three  months.  The  discharge  then  almost  ceased,  there  being  only 
occasionally  a  small  drop  in  the  morning. 

^Vhen  he  consulted  me  on  October  5,  1903,  he  complained  of  a  small  swelling  on  the 
under  surface  of  his  urethra,  about  5  centimetres  from  the  meatus.  This  tumour, 
which  had  been  noticed  about  three  weeks  previously  as  a  shotty  lump  of  the  size  of 
a  small  pea,  had  suddenly  increased  during  the  last  six  days.  When  I  saw  it  first,  it 
was  of  the  size  of  an  olive,  and  appeared  to  be  on  the  point  of  bursting.  It  had  also 
given  rise  to  edema  of  the  prepuce. 

I  now  urethroscoped  the  patient.  I  introduced  the  instrument  far,  and  then 
gradually  withdrew  it,  until  I  reached  the  swelling.  Curiously  enough,  there  was 
hardly  anj^  bulging  into  the  lumen  of  the  urethra,  although  the  projection  on  the  out- 
side was  unmistakable,  and  of  the  size  of  an  olive. 

Having  found  the  exact  level  of  the  tumour  by  external  palpation,  I  brought  the 
end  of  my  tube  exactly  up  to  it,  and  thrust  KoUmann's  small  knife  through  the  urethral 
mucosa  into  the  substance  of  the  swelling.  Despite  the  length  of  my  incision,  nothing 
but  blood  came  away.  I  then  gripped  penis  and  urethroscopic  tube  firmly  with  one 
hand,  and  made  strong  pressure  on  the  tumour  with  the  other.  In  this  way  I  was  able 
to  express  its  contents,  and  suddenly  a  big,  softish,  but  consistent  slough  came  away, 
which  was  not  unlike  the  core  of  a  boil.  The  size  of  the  swelling  became  less,  but  it 
remained  considerable  owing  to  its  thick  fibrous  shell. 

The  sequelae  were  uneventful.  After  a  few  days,  regular  methodical  dilatation  of 
the  anterior  urethra  with  straight  sounds  could  be  instituted.  It  was  continued  until 
No.  60  G  had  been  reached. 

Five  months  later  I  saw  the  patient  again;  there  was  no  trace  of  any  discharge. 
The  tumour,  which  had  been  as  large  as  an  olive,  was  replaced  by  a  hard,  fibrous 
nodule  of  the  size  of  a  hempseed. 

This  case  is  interesting  in  several  respects,  for  it  shows  that — 

1.  When  the  glands  have  ceased  to  communicate  with  the  surface  of  the 
urethral  mucosa,  the  endoscopic  examination  gives  no  indication  as  to  their 
seat  and  their  conditio  n. 

2.  The  contents  of  these  follicles  are  not  liquid,  but  are  formed  by 
sloughs  not  unlike  the  core  of  a  boil. 

3.  These  cysts  are  mainly  composed  of  a  thick  fibrous  shell  formed  by 
the  connective-tissue  infiltration. 

4.  It  is  easy  to  attack  these  inflamed  glands  surgically  through  .the 
urethroscope  when  they  threaten  to  suppurate.  This  mode  of  operating 
prevents  their  spontaneous  or  artificial  opening  through  the  skin,  and  thus 
avoids  the  subsequent  formation  of  a  urinary  fistula. 

The  lacunae  of  Morgagni  are  apt  to  be  affected  similarly,  by  obliteration 
of  their  ducts,  with  engorgement  and  with  condensation  of  their  contents. 
The  picture  they  give  under  the  urethroscope  is  quite  characteristic.     Hardly 


172  GONOERHEA 

any  or  no  glandular  orifices  are  visible.  Here  and  there  one  observes, 
instead  of  a  lacunar  orifice,  a  small  greyish  or  yellowish  depression,  which 
indicates  a  closed  follicle,  and  is  represented  by  small  spots  of  the  size  of 
a  millet-seed.     These  follicles  are  sensitive  when  one  palpates  the  urethra. 

I  have  shown  a  case  of  this  type  (Plate  III.,  Fig.  6)  in  which  a  tacuna  of  Morgagni  was 
obliterated.  This  patient,  a  man  of  twenty-nine,  had  had  a  discharge  for  over  a  year, 
and  presented  multiple  lesions  of  chronic  urethritis :  prostatitis,  hard  infiltrations  at 
the  perineum,  and  glandular  and  lacunar  lesions  in  the  penile  portion.  The  urethro- 
scope allowed  me  to  distinguish  clearly  a  small  oval  swelling  of  the  size  of  a  wheat- 
grain  on  the  upper  surface  of  the  urethra.  It  was  covered  by  a  thick,  yellow,  smooth 
mucosa  which  showed  a  few  red  striae. 

This  clearly  defined  and  well-localized  lesion  was  dilated  with  KoUmann's  dilator 
up  to  No.  42  G,  but  the  therapeutic  effect  was  nil.  Its  aspect  under  the  urethroscope 
was  exactly  the  same  as  before.  I  therefore  touched  it  up  with  KoUmann's  electrolytic 
needle  two  or  three  times  in  one  sitting,  the  needle  being  applied  almost  at  the  same 
spot  every  time.     This  treatment  settled  the  whole  matter. 

One  not  infrequently  finds  both  the  glandular  and  the  dry  forms  present 
together  in  urethrse  which  are  affected  with  hard  infiltrations. 

This  is  the  mixed  form.  It  rarely  occurs  spontaneously  in  untreated 
cases.  It  is  commonest  observed  in  cases  of  the  dry  variety  which  are 
treated  with  dilatation.  The  cysts  are  then  opened,  become  atrophic,  and 
disappear.  The  excretory  ducts,  having  been  freed,  open  out  again.  In  this 
way  the  mixed  variety  is  gradually  established,  until  it  is  again  superseded 
by  the  pure  glandular  type. 


5.  Urethroscopy  of  the  Posterior  Urethra  in  Disease. 

In  every  case  of  chronic  infiammation  of  the  urethra  the  posterior 
urethra  should  be  examined,  and  one  should  not  restrict  one's  efforts  to  an 
inspection  of  the  verumontanum.  The  investigation  should  be  complete, 
and  should  include  the  "  prostatic  fossette  " — i.e.,  it  should  begin  at  the 
neck  of  the  bladder. 

Even  when,  clinically,  no  symptoms  point  to  a  lesion  of  the  posterior 
urethra,  such  lesions  are  often  present,  and  they  would  never  be  diagnosed 
unless  one  resorted  to  urethroscopic  examination. 

Very  often  a  patient  has  no  abnormal  sensations  about  his  prostate, 
the  urine  collected  in  the  last  glass  contains  no  filaments,  the  palpation  fer 
rectum  reveals  no  marked  change  in  the  prostate,  and  even  energetic 
prostatic  massage  yields  only  a  little  normal  secretion,  so  much  so  that  one 
is  inclined  to  consider  these  structures  healthy;  and  yet  lesions  are  present, 
which  an  attentive  urethroscopic  examination  enables  one  to  find  and  to 
cure.  Many  cases  of  this  nature  will  get  perfectly  well  if  they  are  properly 
treated,  despite  their  reputation  of  incurability. 


URETHROSCOPY  173 

When  no  prostatic  lesions  are  responsible  for  the  gleet,  one  may  be 
certain  that  there  is  trouble  in  the  posterior  urethra,  and  it  becomes 
necessary  to  explore  it  in  its  entire  length,  from  the  neck  of  the  bladder 
downwards. 

The  commonest  lesions  in  the  posterior  urethra  are  soft  infiltrations. 
The  mucosa  is  hyperemic  and  congested,  and  bleeds  on  the  slightest 
provocation. 

It  is  commonly  swollen  to  a  marked  degree,  and  displays  small,  more  or 
less  closely  packed  edematous  bulgings,  which  bleed  as  soon  as  they  are 
touched  (Fig.  114). 

The  prostatic  glands  are  very  often  affected.  They  are  red,  swollen, 
and  encircled  by  a  prominent  edge.     Goldschmidt  has  compared  them  very 


Fig.  114.— Lesions  of  the  "Prostatic  Fossette"  behind  the  Verumontanum, 

AS   SEEN   with  THE   URETHROSCOPE., 

happily  with  frog's  eyes.  In  certain  cases  they  form  small  apposed,  purulent 
masses  not  unUke  little  white  buttons.  Occasionally  they  are  acuminated, 
and  remind  one  of  boils.  These  chronic  prostatic  lesions  are  not  only  to 
be  found  in  the  region  behind  the  verumontanum  and  on  the  lower  wall; 
they  are  also  met  with  on  the  upper  surface  of  the  urethra  and  in  the  grooves 
to  either  side  of  the  verumontanum.  For  this  reason  a  straight  urethro- 
scopic  tube  gives  a  much  better  view  than  the  instruments  designed  especially 
for  the  posterior  urethra. 

It  is  impossible  with  Goldschmidt's  apparatus,  for  instance,  to  examire 
the  antero-superior  wall  of  the  prostatic  urethra.  If  one  were  to  rely  solely 
on  instruments  of  this  type,  one  would  never  see  certain  definite  lesions  of 
the  posterior  urethra,  as  the  following  case  shows  (see  also  Fig.  116): 


174  GONOERHEA 


Chronic  Posterior  Urethritis  due  to  a  Focus  in  the  Prostate  which 

CONTAINED    GONOCOCCI   FOR  OVER  TeN  YeARS. 

A  man  of  forty-four  was  sent  to  me  (by  Dr.  Portalier)  who  had  acquired  an  attack 
of  gonorrhea  when  he  was  thirty-four.  He  had  been  treated  with  permanganate 
irrigations,  had  got  rid  of  his  discharge,  and  had  remained  without  any  appreciable 
discharge  for  ten  years.  Suddenly,  in  May,  1910,  a  copious  discharge  was  noticed 
which  contained  a  great  number  of  gonoccoci.  The  patient,  who  was  much  surprised, 
began  to  suspect  his  mistress,  and  brought  her  to  me  for  examination. 

I  examined  her  most  carefully  on  two  occasions,  and  failed  to  discover  any  gonococci 
in  the  urethra,  which  was  urethroscoped,  or  in  the  para-urethral  glands,  or  in  those  of 
Bartholin,  or  in  the  posterior  vaginal  fornix,  or  in  the  cervix,  which  was  scraped  with  a 
platinum  loop.     The  rectum  was  also  explored,  and  found  to  be  healthy. 

The  young  woman  was  thus  apparently  quite  free  from  gonorrhea,  and  the  origin 
of  the  infection  seemed  thus  inexplicable.  I  reduced  and  finally  cured  the  discharge 
by  means  of  KMnO^  injections.  This  result  was  rapidly  obtained,  so  much  so  that  on 
May  27  the  urine  had  become  clear,  and  a  urethroscopic  examination  could  be  made 
under  favourable  conditions. 

To  my  great  surprise,  I  discovered  some  definite  soft  infiltrations  just  in  front  of 
the  verumontanum,  whilst  the  region  behind  it,  near  the  neck  of  the  bladder,  was 
perfectly  healthy. 

In  front  of  the  verumontanum,  edematous  bulgings,  small  polypi,  and  polypoid 
vegetations,  were  present,  and  the  surface  of  the  mucosa  was  raised  by  edema.  The 
bulb  and  the  penile  urethra  were  quite  normal.  It  was  thus  clear  that  I  was  dealing 
with  a  very  old  chronic  lesion  of  the  posterior  urethra,  which  had  given  the  gonococcus 
shelter  for  ten  years,  and  which  had  only  recently  flared  up  suddenly  for  some  reason 
or  other. 

The  urethra  was  dilated,  first  with  metal  sounds,  and  then  with  Frank's  three- 
bladed  dilator,  until  a  high  degree  of  dilatation  was  reached.  The  lesion  in  the  prostatic 
urethra  was  readily  healed  in  this  way,  and  the  patient  cured. 

Control  by  means  of  the  urethroscope  after  the  dilatation  with  Frank's  instrument 
showed  that  no  lesions  were  left. 

Another  equally  typical  case  is  the  following : 

A  man  of  forty-five  had  a  purulent  discharge  containing  gonococci  for  six  months. 
Dr.  Wormser,  who  treated  him,  irrigated  him  with  KMnO^,  and  then  dilated  his  urethra 
methodically  with  curved  sounds  up  to  56  G. 

A  concomitant  inflammation  of  Tyson's  gland  was  treated  by  incision,  and  had 
subsided  when  I  saw  the  patient. 

Despite  this  very  methodical  and  scientific  treatment,  the  discharge  reappeared, 
and  contained  again  gonococci  as  soon  as  the  irrigations  were  stopped.  The  presence  o^ 
a  nermanent  focus  was  thus  to  be  feared,  and  Dr.  Wormser  asked  me  to  find  it  (June  6, 
1910). 

The  palpation  of  the  urethra  on  a  sound  revealed  no  littritis.  The  changes  in  the 
prostate  were  insignificant;  Cowper's  glands  and  the  vesicles  were  normal.  There  was 
nothing  wrong  with  the  testicles  and  their  epididymes,  which  had  never  been  inflamed. 

Urethroscopic  examination  proved  the  anterior  urethra  to  be  normal,  but  revealed 
definite  lesions  in  the  posterior.  Here  smaD,  whitish,  purulent  vesicles  were  present 
just  above  the  verumontanum,  in  the  bolster  of  mucous  membrane  which  covers  it.  It 
was  impossible  to  detach  them  with  a  swab,  as  the  latter  simply  passed  over  them  with- 
out damaging  their  walls. 

A  precise  lesion  which  contained  gonococci  was  thus  found,  and  I  advised  Dr. 
Wormser  to  continue  his  dilatation  treatment.     The  patient  was  subsequently  dilated 


EXPLANATORY  TEXT  TO  PLATE  III 


Pigs.  1  and  2. — PJncysted  Purulent  Glands  of  Littre. 

A  glance  at  these  two  figures  enables  one  to  realize  the  importance  of 
far-pushed  urethral  dilatations.  The  case  in  point  is  described 
on  p.  169. 


Fig.  3. — Glands  of  Littre  in  a  State  of  Chronic 
Inflammation. 

Fig.  4. — Chronic  Inflammation  of  Morgagni's  Lacuna  and  of 
Littre' s  Glands. 

The  picture  is  typical  and  often  observable.     Around  each  focus  is 
a  characteristic  inflammatory  halo. 

Fig.  5.^ — Enormous  Encysted  Gland  of  Littre,  v/hich  burst 
readily  under  the  Action  of  a  Few  Dilatations. 

The  case  is  described  on  p.  170. 

Fig.  6. — Chronic  Inflammation  of  a  Lacuna  of  Morgagni. 

Its  complete  disappearance  could  only  be  obtained  by  means  of  several 
direct  applications  with  the  electrolytic  needle.  The  case  is  de- 
scribed on  p.  172. 

To  face  page  VI 4:. 


Georges  LUYS 


Planclie  IE. 


PiA.l 


F16.2. 
& 


Fid.  3 


.      FiQ .  4^ 


P16.  5 


Imp .  L  L  afoTilame ,  Paris . 


F1Q.6 


URETHROSCOPY  175 

tip  to  No.  60  G,  but  after  four  days  had  elapsed,  during  which  the  u-rigations  with 
KMnO^  were  stopped,  a  discharge  containing  gonococci  reappeared.  I  therefore  examined 
him  again  with  the  urethrofcope  on  July  1,  1910,  and  found  that  the  old  focus  was 
still  present  and  had  not  altered.  The  recurrence  was  thus  explained,  and  I  proceeded, 
in  agreement  with  Dr.  Wormser,  to  dilate  with  Frank's  dilator  up  to  its  limit,  which 
was  reached  on  July  13. 

The  patient  now  remained  without  any  irrigations  for  six  days,  and  wrote  that  his 
condition  was  satisfactory,  and  that  there  was  no  relapse. 

This  last  dilatation  thus  appeared  to  have  done  its  duty,  and  to  have  destroyed  the 
rebellious  focus  in  which  the  gonococci  were  lodged. 

I  saw  the  patient  again  on  July  25,  1910.  He  had  now  been  fourteen  days  mthout 
any  dilatation -or  irrigation.  He  was  free  from  discharge,  and  there  were  no  filaments  in 
the  urine.  The  urethroscopic  examination  showed  that  all  the  purulent  little  cysts 
had  disappeared  from  the  posterior  urethra,  and  that  there  was  no  lesion  left  which 
could  harbour  gonococci. 

TheTerumontanum  was  still  in  a  slight  state  of  chronic  inflammation  and  somewhat 
edematous.  I  therefore  cauterized  its  apex,  which  projected  a  little  more  than  usual, 
and  painted  its  body  with  iodine  tincture. 

From  this  moment  the  cure  was  certain,  and  there  was  no  chance  of  the  gonococcus 
reappearing. 

The  condition  of  the  posterior  urethra  in  acute  urethritis  cannot  be  made 
out  by  means  of  urethroscopy,  as  this  method  is  contra-indicated  in  these 
cases.  In  chronic  urethritis  this  portion  is  very  commonly  afiected,  although 
the  contrary  is  usually  believed.  One  should  nsvsr  fail  to  examine  it 
thoroughly,  and  very  often  cases  which  appeared  obscure  will  become  under- 
stood. 

The  "  prostatic  fossette,"  for  instance,  may  show  interesting  changes. 
The  orifices  of  some  of  the  prostatic  glandules  open  on  its  floor.  When 
they  are  infected,  this  fossette  is  often  converted  into  a  regular  cesspool; 
and  if  one  urethroscopes  and  massages  the  prostate  simultaneously,  one  is 
not  infrequently  able  to  see  the  pus  being  discharged  into  it. 

The  glandules  which  are  mo3t  commonly  infected  open  along  the 
lateral  borders  of  the  verumontanum.  In  two  cases  of  chronic  prostatitis 
which  were  absolutely  incurable  by  ordinary  means,  I  was  able  to  express 
pus  by  massaging  the  prostate  per  rectum,  and  I  could  see  it  come  out 
through  these  orifices  along  the  sides  of  the  verumontanum.  It  seemed, 
however,  that  these  openings  were  inadequate,  and  therefore  I  enlarged 
them.  In  the  case  of  a  patient  aged  thirty -four  I  discovered,  after  having 
increased  the  orifice,  an  enormous  cavern,  which  I  disinfected  by  touching 
its  -v^alls  with  silver  nitrate.  Both  cases  afford  a  clear  proof  of  the  necessity 
of  resorting  to  urethroscopy  in  rebellious  inflammations  of  the  prostate. 
On  each  occasion  a  huge  cavity  was  present  behind  a  minute  orifice,  which 
certainly  was  inadequate  for  its  drainage.  With  the  expoiure  of  the  cavern 
and  its  disinfection  the  incurability  disappeared.  The  solution  of  the 
problem  of  curing  these  cases  of  rebellious  prostatitis  lies  in  this  direction. 

The  mucous  membrane  of  the    posterior  urethra  undergoes  marked 


176  GONORRHEA 

changes  in  hard  infiltration.  The  membranous  portion  assumes  a  reddish- 
grey  and  shghtly  yellowish  aspect;  its  lustre  disappears;  it  becomes  dry  and 
dull. 

The  epithelium  undergoes  desquamation.  It  is  often  denuded  over  a 
large  area,  and  hence  it  bleeds  so  readily  when  the  urethroscopic  tube  is 
being  introduced. 

The  numerous  folds  which  are  present  in  health  disappear  almost  com- 
pletely owing  to  the  fibrosis.  When  this  process  is  far  advanced,  nothing 
but  a  rigid  tube  is  left,  which  is  of  a  yellowish-white  tint  or  of  the  colour  of  a 
pearl.  This  latter  colour,  if  pronounced,  is  practically  always  indicative  of 
pachydermia. 

Vegetations  and  'polypi  are  also  not  uncommon  in  the  posterior  urethra, 


Fig.  115. — Polypus  on  the  Verumontanxjm. 

and  are  often  accompanied  by  neurasthenic  troubles,  which  may  assume  a 
serious  character. 

Sometimes  they  are  situated  on  the  verumontanum,  as  shown  in  Fig.  115. 
In  this  case  the  condition  present  imitated  a  cock's  comb,  and  the  polypus 
was  readily  destroyed  by  means  of  the  cautery.  When  these  growths 
form  in  the  membranous  portion,  they  are  usually  pedunculated,  and  have 
a  long  pedicle.  Or,  again,  they  may  take  the  shape  of  a  "cauliflower 
growth"  and  occupy  the  whole  prostatic  portion,  covering  the  verumon- 
tanum completely,  or  the}^  may  resemble  an  eel  (Fig.  117)  or  a  phallus 
(Fig.  118),  etc. 

These  cases  are  most  difficult  to  treat;  they  require  energetic  cauteri- 
zation, and  at  the  same  time  one  has  to  avoid  damaging  the  ejaculatory  ducts. 


URETHROSCOPY 


177 


One  of  my  patients,  a  man  of  thirty-five,  had  a  constantly  recurring  discharge  which 
contained  gonococci.  This  was  due  to  a  lesion  in  the  posterior  urethra,  which  wag 
completely  filled  with  raspberry-like  vegetations.     I  dilated  with  Frank's  instrument 


Fig.  116.— Glandular  Lesions  of  the  Anterior  Part  of  the  Prostate,  as  seen 

WITH  the  Urethroscope. 


FiG.  117. — Long  Eel-shaped  Polypus  attached  to  the  Anterior  Aspect  of 

the  Verumontanum. 


up  to  45  G,  but  the  discharge  recurred.  I  then  urethroscoped  him,  and  cauterized 
the  whole  posterior  urethra  with  the  galvano-cautery.  It  was  impossible  to  spare  the 
verumontanum,  and  thus  the  ejaculatory  ducts  were  exposed,  as  shown  in  Fig.  5  on 

12 


178  GONOEKHEA 

Plate  II.  The  urethroscopic  image  is  rather  curious.  The  verumontanum  has  dis- 
appeared, and  the  two  ejaculatory  ducts  are  plainly  visible  in  apposition  to  each  other, 
like  the  barrels  of  a  gun. 

The  orifice  of  the  prostatic  utriculus  often  gapes,  and  occasionally 
seminal  fluid  can  be  seen  to  ooze  from  its  hollow. 

In  certain  cases,  in  which  it  is  necessary  to  differentiate  between  secre- 
tions from  the  prostate  and  those  from  the  seminal  vesicles,  it  is  possible, 
by  combining  the  urethroscopic  examination  with  simultaneous  rectal 
massage,  to  express  the  contents  of  the  vesicles  from  the  utriculus  in 
front  of  one's  eye.  In  this  way  one  is  enabled  to  guide  one's  therapy 
appropriately. 


Fig.  118. — Phaixus-shaped  Polypus  arising  on  the  Upper  Aspect  of  the 

Verumontanum. 

In  other  instances  the  utriculus  is  more  or  less  deviated  to  one  side, 
instead  of  being  in  the  middle  of  the  verumontanum.  In  chronic  epi- 
didymitis a  purulent  secretion  is  occasionally  seen  to  issue  from  it;  or  its 
lips  are  congested,  warty,  and  bleed  at  the  sKghtest  contact.  This  morbid 
finding  corresponds  to  a  clinical  sign  which  patients  suffering  from  posterior 
urethritis  occasionally  complain  of:  blood-stained  ejaculations. 

When  the  verumontanum  is  invaded  by  sclerosis,  it  becomes  yellowish, 
shrunk,  and  withered.  The  utriculus  and  the  ejaculatory  ducts  are  then 
often  narrowed  or  strangled.  These  lesions  are  responsible  for  the  sudden 
violent  pain  which  some  patients  feel  at  the  moment  of  ejaculation. 

Occasionally  one  meets  with  cases  in  which  the  verumontanum  is 
uniformly  enlarged  and  hypertrophied.  It  would  seem  that  this  con- 
dition were  the  outcome  of  habitual  masturbation,  so  much  so  that  I  have 


UKETHKOSCOPY  179 

often,  on  finding  this  condition  present,  accused  the  patients  of  this  vice 
and  obtained  a  confession. 

The  vemmontanum  is  swollen,  and  assumes  the  shape  of  a  cervix  uteri 
as  one  finds  it  in  chronic  metritis.  The  utriculus  gapes,  and  bears  a  close 
resemblance  to  an  os  cervicis  which  is  in  a  state  of  chronic  inflammation.^ 

Lastly,  urethroscopic  examination  is  of  extreme  interest  when  the 
prostate  is  hypertrophied.  One  can  thus  ascertain  the  exact  length  of  the 
prostatic  channel,  its  curves,  the  shape  of  its  walls,  and  any  abnormal 
projections!  which  may  be  present,  and  be  responsible  for  the  difficulty  in 
making  water  complained  of  by  the  patient. 


FiOr.  119. — Hyperteophy  of  the  Verumontanthm  EESiiLTrNG  rEOM  Cheonio 

Inflammation. 

This  condition  imitates  a  cervix  uteri,  and  is  usually  found  in 
habitual  masturbators. 

Under  the  control  of  the  eye  these  projections  which  interfere  with 
micturition  can  be  destroyed,  and  thus  this  process  is  of  therapeutic  value. 

It  is  hardly  necessary  to  point  out  that  these  urethroscopic  interventions 
cannot  take  the  place  of  suprapubic  (transvesical)  prostatectomy.  But 
they  are  useful  in  certain  cases,  and  they  are  certainly  to  be  preferred  to 
the  blind  cutting  of  Bottini's  operation,  because  they  are  done  under  the 
control  of  the  eye. 

^  This  pathological  finding  has  as  clinical  equivalent  the  feeling  of  moisture  about 
their  urethra  which  so  many  masturbators  complain  of,  and  the  sensation  that  their 
semen  is  running  away  from  them.  To  this  loss  of  semen  they  often  attribute  their 
weakness,  their  insomnia — in  fact,  all  their  little  ailments.  It  becomes  a  regular 
obsession,  and  sometimes  drives  them  to  suicide  (A.  P.). 


180  GONOERHEA 


6.  Urethroscopic  Examination  or  the  Female  Urethra. 

Urethroscopic  examination  of  the  female  urethra  is  at  least  as  necessary 
as  the  corresponding  exploration  in  the  male. 

In  both  sexes  the  urethra  has  to  be  dilated  sufiQ.ciently  beforehand. 

For  the  female  urethra  one  uses  a  short  tube  like  the  one  shown  in 
Fig.  81  (p.  137). 

In  women,  the  neck  of  the  bladder  is  frequently  involved  in  the  course 
of  chronic  urethritis,  and  requires  to  be  examined  at  the  same  time  as  the 
posterior  urethra.  Now,  a  simple  urethroscopic  tube  gives  a  blurred  picture 
if  one  pushes  it  into  the  bladder,  because  some  urine  enters  the  tube  and 
prevents  one  from  seeing  distinctly.  It  is  therefore  advisable  to  have  a 
special  instrumental  outfit,  such  as  my  direct  vision  cystoscopy 

Description  of  my  Direct  Vision  Cystoscope. — My  direct  vision  cysto- 
scope  for  woman  consists  of  a  hollow  metal  tube  which  is  10  centimetres 
long.  As  the  female  urethra  can  be  dilated  without  difficulty,  a  tube 
No.  59  Gr  is  generally  employed. 


Fig.  120. — Ltjys's  Direct  Vision  Cystoscope  (Female  Pattern). 

The  lower  wall  of  the  tube  contains  a  minute  channel,  through  which 
the  urine  collected  in  the  badder  is  aspirated.  Owing  to  a  special  con- 
struction, this  aspiration  tube  is  not  soldered,  and  does  not  project  to  any 
appreciable  extent  into  the  cystoscopic  tube.  One  connects  it  through  a 
rubber  pipe  with  a  receiver,  in  which  a  vacuum  is  made  and  maintained  by 
means  of  a  filter  pump. 

Along  the  whole  length  of  the  upper  wall  of  the  cystoscopic  tube  runs 
a  groove,  which  forms  a  kind  of  bed  for  the  lamp  and  its  holder.  The  latter, 
therefore,  do  not  project  into  the  lumen  of  the  tube,  and  do  not  reduce  the 
field  of  vision. 

The  instrument  is  introduced  by  means  of  a  straight  metal  pilot,  and 
is  illuminated  by  means  of  a  small  electric  lamp  which  is  fixed  to  a  long 
holder,  which  brings  it  down  to  the  level  of  the  mouth  of  the  urethroscopic 
tube.  Lamp  and  tube  are  attached  to  a  handle,  which  does  not  difier  from 
the  handle  of  my  urethroscope  {vide  Fig.  82). 


URETHROSCOPY 


181 


Fig  121. — Ltjys's  Direct  Vision  Cystoscope  completely  Mounted 
(Female   Pattern). 


Fia.  122  — The  Author's  Consulting-Room  Table  for  examining  the  Urinary 
Organs  (Horizontal  Position). 


182  GONOEEHEA 

Technique  of  Direct  Vision  Cystoscopy. — The  cystoscopic  tube  and  its 
pilot  are  sterilized  by  boiling.  The  lamps  are  disinfected  by  the  action 
of  formalin  vapours.     The  lens  and  the  wires  are  attached  to  the  handle. 

Within  easy  reach  should  be  a  table  carrying  an  hermetically-closed 
vessel  which  is  fitted  with  a  two-holed  stopper.  The  tubes  which  pass 
through  these  holes,  are  connected  by  means  of  rubber  tubing  with  the 
aspiration  tube  of  the  cystoscope  and  with  the  filter  pump  respectively, 
A  vacuum  can  thus  be  made  within  the  vessel,  and  the  urine  can  be  aspi- 


FiG.  123.— The  Authok's  Special  CoNSHLTrNG-RooM  Table  for  Cytsoscopy 
WITH  THE  Direct  Vision  Cystoscope. 

rated  into  it.^  Sterile  mounted  swabs  for  drying  the  urethral  mucous  mem- 
brane should  be  at  hand.  They  are  also  useful  for  removing  any  blood 
which  may  come  from  the  bladder  if  some  cystitis  is  present. 

The  patient  should  take  off  all  her  clothes  excepting,  her  chemise.  One 
begins  by  washing  the  bladder,  either  with  a  syringe  or  from  an  irrigator, 
until  the  fluid  is  returned  quite  clear.  Once  this  has  been  accompHshed, 
the  bladder  is  emptied  completely.  The  patient's  pelvis  is  then  raised 
and  brought  to  the  edge  of  the  table.  The  head  is  lowered,  and  firm  sup- 
ports are  fitted  to  the  shoulders  in  order  to  prevent  the  patient  from 


URETHROSCOPY 


183 


wriggling  away  from  the  surgeon.  These  rests  should  be  firmly  fixed  to  the 
table,  and  should  be  selected  according  to  the  size  of  the  patient. 

The  feet  should  be  supported  by  stirrups  or  by  American  leg-rests. 
The  important  point  is  to  fix  the  legs  and  to  separate  them  well.  The  head 
may  be  conveniently  raised  by  a  small  pillow. 

When  all  the  preparations  are  finished,  the  cytoscopic  tube  is  passed. 
If  a  large  size  has  been  chosen — say  59  G — it  is  well  to  begin  by  dilating 
the  urethra  with  Hegar's  bougies  (6,  7,  8,  and  9).^  The  cystoscope  can 
then  be  passed  with  the  greatest  ease. 


L.    Jiu 


Fig.  124. — Examination  of  the  Bladder  by  Means  op  the  Direct  Visioir 

'  Cystoscope. 

If  the  meatus  is  somewhat  narrow,  and  if  the  manipulations  are  likely 
to  cause  pain,  it  is  advisable  to  insert  a  piece  of  wool  which  has  been  soaked 
in  a  5  or  10  per  cent,  solution  of  stovain  (or  other  anesthetic)  into  the 
meatus,  and  to  leave  it  there  for  a  few  minutes  before  one  attempts  to  pass  the 
tube.     This  procedure,  which  has  been  advocated  by  Kelly,  is  excellent. 

The  meatus  having  been  washed  and  disinfected,  the  cystoscopic  tube 
and  its  pilot  are  lubricated  with  glycerine  and  introduced  very  gently 
into  the  urethra.     The  instrument  reaches  the  bladder  with  the  greatest 

^  Or  straight  metal  sounds  of  suitable  size  (A.  F.). 


184 


GONORKHEA 


ease  in  this  way.  One  then  withdraws  the  pilot,  and  puts  the  aspirator, 
into  action  in  order  to  dry  the  tube  and  to  prevent  the  lamp  from  being 
ai!ected  by  moisture. 

The  handle  and  the  lamp  are  then  fitted  on  to  the  tube  of  the  cystoscope, 
and  fixed  by  turning  the  special  screw.  Once  the  light  is  switched  on,  the 
bladder  is  beautiiully  illuminated,  and  shows  all  its  details. 

In  Trendelenburg's  position  the  bladder  is  relieved  of  the  weight  of  the 
viscera,  which  rest  on  it  normally,  and  expands.  The  cystoscope  is  thus 
free  within  its  cavity,  and  can  be  moved  about  in  all  directions. 


Fig.  125.— Examination  of  the  Bladder:  Exact  rosiTioN  of  the  Direct  Vision 
Cystoscope  during  the  Examination  of  the  Female  Bladder  and  Urethra. 

The  examination  of  the  lower  wall  of  the  neck  of  the  bladder  is  easily 
carried  out.  One  has  only  to  raise  the  handle  of  the  instrument.  The 
mouth  of  the  tube  within  the  bladder  is  then  lowered,  and  the  whole  trigone 
comes  into  view. 

The  upper  wall  is  examined  in  a  similar  manner,  except  that  the  move- 
ment is  reversed :  one  lowers  the  handle,  and  thus  raises  the  end  of  the  tube 
which  is  in  the  bladder. 

It  is  well,  once  one  has  got  to  this  stage,  to  press,  or  to  ask  the  patient 
to  press,  with  one  hand  on  the  abdominal  wall  just  above  the  pubis.     The 


URETHROSCOPY  185 

whole  upper  part  of  the  bladder  can  then  be  made  to  pass  in  front  of  the 
urethoscope  at  will,  and  can  be  explored  completely. 

The  female  urethra  should  always  be  inspected  in  its  whole  length 
from  the  neck  of  the  bladder  down  to  the  meatus,  whether  one  uses  a 
urethroscopic  tube  or  my  direct  vision  cystoscope. 

Whilst  the  instrument  is  being  slowly  withdrawn,  any  small  polypi  and 
papillomatous  proliferations,  are  carefully  noted,  and  the  openings  of  the 
urethral  glands  are  inspected. 

The  female  urethra  is  composed  of  two  distinct  portions  : 

1.  A  posterior  urethra  close  to  the  neck  of  the  bladder,  which  is  chiefly 
muscular  in  structure.  When  seen  with  the  urethroscope,  this  portion  is 
characterized  by  a  great  number  of  well-marked  radiating  strise,  which 
indicate  the  underlying  muscle  fibres.  It  usually  escapes  inflammation, 
because  it  contains  very  few  glands. 

2.  The  anterior  urethra  is  totally  different.  It  is  well  provided  with 
glands,  and  is  literally  studded  with  their  oriflces.  These  glands  of  the 
female  urethra  are  constant,  and  are  arranged  in  two  important  lateral 
groups.  They  present  the  features  common  to  mucous  glands,  and  open 
into  the  lumen  of  the  urethra  by  oriflces  which  are  sufficiently  large  to  be 
visible  by  means  of  the  urethroscope.  In  their  aspect  and  in  their  structure 
these  glandular  formations  of  the  female  are  absolutely  analogous  to  those 
met  with  in  the  penile  urethra  of  man.  They  are  therefore  the  female 
equivalents  of  Littre's  glands  and  of  Morgagni's  lacunae.  Like  the  latter, 
they  are  prone  to  gonococcal  infection  and  its  consequences.  Their  chronic 
inflammation  is  one  of  the  chief  causes  of  everlasting  gonorrhea  in  the 
woman. 

It  thus  follows  that  gonorrheal  urethritis  in  women  deserves  the  same 
attention  as  gonorrheal  urethritis  in  men,  and  that  the  treatment  of  the 
chronic  cases  should  be  similar — namely,  dilatation. 

A  few  examples  may  here  find  room  to  show  how  necessary  it  is  to 
urethroscope  the  female  urethra,  and  how  this  diagnostic  method  reveals 
the  presence  of  lesions  which  in  the  ordinary  course  of  events  would  never 
have  been  found  : 

On  June  5,  1905,  Professor  Terrier  sent  me  a  lady  of  forty -four  who  had  been 
operated  on  five  years  previously  for  a  vesical  tumour.  Her  urine  was  clear,  and  there 
was  no  frequency;  but  she  complained  of  severe  pain  during  micturition  and  after. 

Thinking  that  her  tumour  had  recurred,  she  had  called  repeatedly  on  Professor 
Albarran,  who  had  performed  the  operation.  He  examined  her,  and  failed  to  find 
any  sign  of  a  recurrence.  She  then  went  to  Professor  Terrier,  who  sent  her  on  to  n  e. 
Clinical  examination  of  the  bladder  showed  nothing  abnormal.  This  organ  had  a 
capacity  of  300  c.c.  There  was  no  pain  on  palpation,  and  the  vesical  walls  were  found 
to  be  normal. 

The  examination  of  the  bladder  with  the  ordinary  cystoscope  confirmed  these 
findings.    The  walls  were  healthy,  and  there  was  no  trace  of  a  recurrence. 


186  GONOREHEA 

A  little  later — on  June  23,  1905 — I  examined  the  patient  again,  but  this  time  with 
my  direct  vision  cystoscope.  Again  I  failed  to  find  anything  wrong  with  the  bladder. 
I  was  on  the  point  of  terminating  my  inspection,  when  I  suddenly  noticed,  as  the 
instrument  was  about  2  centimetres  in  the  urethra,  a  thick,  turbid,  obviously  purulent 
fluid  flooding  the  lumen  of  the  tube. 

I  at  once  aspirated  this  secretion  with  the  filter-pump,  and  dried  the  mucous  mem- 
brane with  swabs.  Inspection  of  the  urethral  w  alls  now  showed  me,  about  2  centimetres 
behind  the  meatus,  an  orifice  which  led  to  a  para-urethral  cavity.  By  pressing  on  it 
with  the  cystoscopic  tube,  a  turbid  liquid  containing  flakes  escaped.  The  diagnosis 
was  now  clear.  The  patient  had  been  suffering  from  a  para-urethral  abscess,  which 
had  burst  owing  to  the  pressure  of  the  tube  on  it. 

The  following  visits  -were  devoted  to  enlarging  the  orifice  by  means  of  the  electric 
cautery,  and  to  applying  silver  nitrate  to  the  interior  of  the  cavity. 

Under  this  treatment  the  pain  complained  of  ceased,  and  disappeared  entirely. 

Another  interesting  case,  which  shows  the  vast  importance  of  urethros- 
copy for  the  diagnosis  of  urethral  and  vesical  afiections  in  women,  is  the 
following : 

A  lady  was  sent  to  me  in  October,  1910,  who  complained  of  pain  in  her  urethra 
and  in  her  bladder  during  micturition,  and  after  the  act.  She  had  been  suffering  in 
this  way  for  seven  months. 

Tn  the  beginning  it  was  extremely  difficult  to  examine  her  owing  to  the  tenderness 
of  her  urethra.  However,  with  a  little  patience,  I  managed  to  dilate  it  gradually, 
and  towards  the  end  of  November  I  was  able  to  pass  my  direct  vision  cystoscope. 

On  November  22,  1910,  I  made  a  thorough  examination  of  her  bladder  and  her 
urethra.  I  found  the  former  organ  and  the  posterior  urethra  perfectly  healthy.  But 
as  I  gradually  withdrew  the  tube,  I  noticed  on  the  left  wall  near  its  middle  a  small 
edematous  orifice,  from  which  a  few  drops  of  pus  escaped.  The  tract  was  so  small 
that  one  could  barely  probe  it  with  a  stylet. 

The  diagnosis  was  certain :  Para-urethral  fistula. 

I  enlarged  the  opening  in  subsequent  visits  with  the  cautery  in  order  to  give  the 
pus  a  free  outlet. 

A  few  days  later  the  patient  passed  masses  of  purulent  flakes,  which  were  examined 
bacteriologically  by  Dr.  Hallion.  No  gonococci  were  found,  nor  was  Koch's  bacillus 
present.  The  infection  was  due  to  undefined  bacteria,  which  were  present  in  great 
quantities. 


CHAPTER  IX 

THE  COMPLICATIONS  OF  GONORRHEA 

The  complications  of  gonorrhea  are  numerous  and  varied;  some  of  them  are 
local,  the  others  are  general. 

LOCAL  COMPLICATIONS. 

Phimosis  and  Paraphimosis. 

A  gonococcal  infection  which  merely  affects  the  glans  and  the  balano- 
preputial  fold  gives  rise  to  balanitis  and  balano-posthitis.  This  compli- 
cation is  especially  frequent  in  patients  with  a  long  and  tight  foreskin,  as 
they  find  it  difficult  to  uncover  the  glans,  and  therefore  do  not  keep  it 
properly  clean.    In  the  circumcised  this  comphcation  is  quite  exceptional. 

Balanitis  manifests  itself  by  a  disagreeable  itching,  tingUng,  and  stinging 
about  the  glans.  After  a  time,  a  whitish  or  yellowish  discharge  appears, 
which  gradually  increases.  The  mucous  covering  of  the  glans  is  swollen, 
claret-coloured,  and  granular  in  aspect.  Later  on,  as  the  inflammation 
becomes  more  acute,  the  patient  finds  it  impossible  to  draw  his  prepuce 
back:  he  suffers  from  phimosis.  The  secretion  becomes  more  and  more 
abundant,  and  is  of  a  yellow  or  greenish  colour,  and  may  even  be  streaked 
with  blood.  The  prepuce  begins  to  swell,  and  the  end  of  the  penis  assumes 
the  shape  of  a  club  or  of  a  bell-clapper.  The  erections  become  painful, 
and  the  patient  cannot  bear  to  touch  his  organ  or  to  allow  it  to  be  handled. 
If  the  inflammation  be  allowed  to  continue  its  course,  gangrene  sets  in  ;  the 
prepuce  usually  sloughs  away  at  the  dorsum,  thus  forming  a  kind  of  button- 
hole, through  which  the  sanious  discharge  accumulated  under  it  finds  an 
outlet.  Subsequently  the  glans  itself  makes  its  way  through  this  opening. 
In  other  cases  it  becomes  impossible  to  bring  the  foreskin  back  into  position, 
once  it  has  been  drawn  back  in  order  to  clean  the  glans.  This  condition  is 
called  "  paraphimosis." 

The  diagnosis  is  usually  easy.  The  only  difficult  point  to  decide  is 
whether  a  simultaneous  inflammation  of  the  urethra  is  present,  or  some 
other  independent  disease,  such  as  vegetations,  soft  sores,  syphilitic  chancres, 
mucous  plaques,  epithelioma,  etc. 

187 


188  GONOREHEA 

The  treatment  of  simple  cases  presents  no  difficulties.  The  glans  and 
the  balano-preputial  fold  are  cleansed  with  a  0-1  per  cent,  solution  of 
subHmate,  and  are  then  dusted  freely  with  a  powder  like  the  following: 

Bismuth  subnitrate  . .  . .  •  •  . .     25  grammes. 

Powdered  talc    . .  . .  . .  -  •  . .     25         ,, 

The  prepuce  is  then  replaced,  covered  by  the  powder,  which  is  renewed 
two  or  three  times  daily. 

When  the  phimosis  is  complete — i.e.,  when  it  is  impossible  to  expose  the 
glans — subpreputial  irrigations  with  a  syringe  are  indicated.  They  should 
be  repeated  several  times  per  day.  As  irrigation  fluid,  a  0.05  per  cent, 
solution  of  sublimate,  or,  better,  a  Ol  per  cent,  solution  of  silver  nitrate 
(or  argyrol),  is  used.  During  the  rest  of  the  time  it  is  well  to  apply  hot 
fomentations  to  the  penis.  Once  the  acute  inflammation  has  subsided, 
the  operation  of  circumcision  should  be  performed.^ 

If  the  balano- posthitis  is  complicated  by  paraphimosis,  reduction  may 
be  attempted  by  exerting  methodical  pressure  on  the  glans,  or  one  may  try 
hot  fomentations.  On  the  whole  it  is,  however,  infinitely  preferable  to 
free  the  constriction  at  once  by  splitting  the  prepuce  in  its  whole  thickness 
until  the  glans  can  be  easily  exposed.  Later  on,  when  the  inflammation  has 
subsided,  the  cosmetic  effect  can  be  improved  by  means  of  a  circumcision.^ 

Dr.  Roux  of  Lorient  utilizes  the  following  method  for  reducing  rapidly 
a  paraphimosis  : 

He  seizes  the  glans  with  the  right  hand,  grips  it  with  the  terminal 
phalanges,  which  are  flexed  upon  the  second  phalanges,  and  then  closes  the 
hand  tightly,  the  thumb  being  crossed  over  the  other  fingers,  which  are 
flexed.  With  the  left  hand  the  pressure  of  the  right  hand  is  reinforced. 
The  penis  is  thus  firmly  compressed  until  the  glans  has  disappeared,  which 
event  takes  place  in  a  minute  or  so.  On  opening  the  hand,  the  glans  is 
decongested,  and  passes  easily  into  the  prepuce. 

Professor  Reclus  facilitates  the  reduction  by  decongesting  the  glans 

^  It  is  often  advisable  to  circumcise  at  once  in  order  to  prevent  further  havoc, 
such  as  extensive  ulceration  and  destruction  of  the  glans,  or  the  formation  of  firm  and 
hard  adhesions  between  prepuce  and  glans.  If  done  properly,  the  operation  is  per- 
fectly successful,  despite  the  suppuration  present.  Many  dread  operating  on  a  very 
septic  prepuce;  this  fear  is  exaggerated.  The  bad  results  in  cases  of  this  kind  are 
nearly  always  due  to  a  too  extensive  removal  of  skin  and  mucous  membrane.  One 
has  to  allow  for  the  edema  of  the  parts  (A.  P.). 

^  The  most  satisfactory  way  of  dealing  with  a  paraphimosis  is  immediate  operation 
by  Legueu's  method,  described  in  Marion  (Georges),  Technique  des  Operations  Courantes, 
Paris  (Maloine),  1904.  I  have  done  this  operation,  which  is  too  little  known,  and  not 
difficult,  fourteen  times,  with  excellent  results.  The  relief  is  immediate,  and  the 
cosmetic  effect  good.  To  "slit  up"  first,  and  to  circumcise  subsequently,  is  an  un- 
necessary procrastination  (A.  P.). 


THE  COMPLICATIONS  OF  GONORRHEA  189 

with  cocain.  The  vaso- constrictive  effect  of  this  drug  is  obtained  by 
applying  a  piece  of  cotton- wool  which  has  been  saturated  with  a  solution 
of  cocain. 

Inguinal  Adenitis. 

Inguinal  adenitis  is  commonly  present  in  gonorrhea.  When  the  lym- 
phatic reaction  is  due  to  an  inflammatory  complication  affecting  the  glans 
or  prepuce — as  is  the  case  in  phimosis  or  paraphimosis — the  inguinal  glands 
increase  considerably,  and  often  give  rise  to  sufficient  pain  and  discomfort 
to  alarm  the  patient.  One  should  in  these  cases  pay  less  attention  to  the 
adenitis  than  to  its  cause,  and  should  look  for  any  ulcerations  on  the  glans, 
on  the  prepuce,  in  the  balano-preputial  fold,  and  even  about  the  anus. 

The  inguinal  adenitis  should  be  treated  indirectly — namely,  by  treating 
these  various  lesions.  It  then  very  often  subsides  spontaneously  without 
requiring  any  local  treatment. 

Suppuration  of  the  inguinal  glands  is  not  common.  When  it  occurs, 
it  should  be  dealt  with  in  the  same  manner  in  which  other  collections  of 
pus  are  treated — namely,  by  a  wide  incision,  followed  by  drainage  and 
curettage.^ 

Even  when  neither  balanitis  nor  phimosis  is  present,  inguinal  adenitis 
is  much  more  common  in  gonorrhea  than  is  usually  believed.  This  in- 
flammation of  the  inguinal  lymphatic  glands  is,  however,  an  insignificant 
reaction.  The  glands  seldom  reach  the  size  of  a  bean,  and  give  rise  to  no 
symptoms,  so  much  so  that  most  patients  are  unaware  of  their  adenitis. 

In  itself  this  reaction  of  the  inguinal  lymphatics  is  of  no  consequence. 
I  have  often  found  them  enlarged  when  Littre's  glands  in  the  anterior 
urethra  were  in  a  state  of  acute  or  chronic  inflammation. 


Inflammation  of  the  Glands  of  the  Anterior  Urethra. 

LiTTRITIS   AND   FOLLICULITIS. 

The  glands  in  the  penile  portion  of  the  urethra — the  glands  of  Littre — have 
already  been  described  {vide  p.  61).  Their  inflammation,  which  is  called, 
according  to  its  intensity,  littritis  or  folliculitis,  is  by  far  the  most  common 
comphcation  of  gonorrhea,  and  seems  to  be  caused  chiefly  by  clumsy 
injections,   such  as  injections  given  with  a  small  syringe  and  urethro- 

^  I  have  not  found  these  long  incisions  satisfactory.  The  edges  of  the  wound 
generally  become  mfected,  and  take  a  very  long  time  to  heal.  Small  incisions  are 
infinitely  preferable.  They  are  quite  sufficient,  if  one  attends  to  the  wound  daily, 
keeps  it  open,  and  empties  it.  They  heal  quickly,  and  the  cosmetic  effect  is  excellent, 
as  they  leave  an  insignificant  and  almost  invisible  scar  (A.  F.). 


190 


GONOERHEA 


vesical  irrigations  which  fail  to  reach  the  bladder,  or  only  enter  it  with 
difficulty. 

As  a  rule,  the  patient  does  not  know  that  he  is  suffering  from  httritis. 
This  complication  is  nearly  always  painless,  and  unless  a  rebelUous  discharge 
accompanies  it,  he  does  not  consult  a  specialist,  who  would  "  touch  the 
spot." 

The  pathogeny  of  httritis  and  folliculitis  is  nowadays  well  known.  The 
glands  of  Littre  are  invaded  by  the  gonococcus,  and  suppuration  takes 
place.  After  a  short  time  their  excretory  ducts  become  obhterated,  with 
the  result  that  the  secretions  formed  in  the  closed  glandular  pouch  can  no 
longer  escape.  With  the  retention  the  glands  enlarge,  and  their  walls 
become  thickened.     Palpation  as  directed  above  {vide  p.  100)  allows  one  to 


ili[jl^^^ 

— j 

1 
1 

K'- 

■  m 

^k 

;-i 

pi..— . ., 

'1 

HV 

^pF' 

ttiMii^ 

■/J-  -f^o 

,  .J 

Fig.  126. — Gonorbheal  Pebi-Urethritis  of  Glandulab  Origin 

(Legueu.) 

feel  the  inflamed  glands  as  small  characteristic  nodules.  When  the  in- 
flammation does  not  extend  beyond  the  gland  wall,  a  simple  littritis  is 
present,  and  as  a  rule,  a  number  of  these  glands  are  affected  simultaneously 
in  the  penile  portion. 

If,  on  the  other  hand,  the  inflammation  spreads  to  the  periglandular 
ceUular  tissue,  the  volume  of  the  inflamed  gland  may  reach  a  considerable 
size;  it  may  become  as  large  as  a  cherry-stone,  or  even  as  a  cherry  or  a  hazel- 
nut. One  then  speaks  of  "  folHcuhtis."  This  condition  is  usually  suffi- 
ciently obvious  to  attract  the  attention  of  the  patient,  who  notices  with 
horror  a  hard,  round,  or  oval,  movable  swelHng  immediately  under  the  skin 
which  covers  the  under- surface  of  his  penis.  In  the  usual  course  of  events 
these  lesions,  which  are  seldom  painful,  tend  to  open  spontaneously  on  the 
skin.  Fistulse  are  thus  formed  which  may  last  indefinitely,  and  even 
urinary  fistulse  may  develop,  from  which  a  few  drops  of  urine  dribble  every 


THE  COMPLICATIONS  OF  GONORRHEA  191 

time  the  patient  makes  water  ;  or  a  peri- urethral  celMitis  may  supervene 
which  gives  rise  to  an  abscess,  and  requires  immediate  incision. 

It  is  highly  desirable  to  prevent  the  formation  of  these  sinuses  and 
fistula?  under  all  circumstances,  and  therefore  the  treatment  of  httritis 
and  folliculitis  should  be  largely  prophylactic.  The  patients  should  be 
warned  against  the  dangers  of  clumsy  injections  and  irrigations,  and  should 
be  informed  of  their  Hability  of  producing  these  comphcations. 

When  the  littritis  is  established,  proper  urethro-vesical  irrigations  should 
be  instituted,  and  they  should  be  combined  later  on  with  methodical  gradual 
dilatation  {vide  Chapter  XII.).  As  far  as  the  penile  urethra  is  concerned, 
this  treatment  should  be  persevered  with  until  a  high  degree  of  dilatation 
has  been  reached.^ 

In  the  case  of  foUicuhtis  this  treatment  may  be  given  a  trial.  But  as 
soon  as  the  urethra  has  been  sufficiently  widened  to  admit  an  endoscopic 
tube  of  some  size,  an  attempt  should  be  made  to  incise  the  inflamed  follicle 
through  the  urethroscopic  tube  with  a  knife.  A  typical  case  of  this  kind 
has  been  described  on  p.  171.  In  the  last  instance,  when  all  these  methods 
have  failed,  surgical  excision  of  the  follicle  should  be  resorted  to. 

Cowperitis. 

Although  cowperitis  is  not  a  frequent  comphcation  of  gonorrhea,  it 
should  always  be  looked  for,  because  in  most  cases  it  escapes  observation. 
Moreover,  if  the  gonococci  are  localized  in  Cowper's  glands,  the  disease  is 
apt  to  last  indefinitely,  unless  it  be  diagnosed  and  treated. 

In  most  cases  it  is  difficult  to  find  a  definite  cause  for  the  infection  of 
these  glands.  It  would,  however,  appear  as  if  here,  again,  clumsy  injec- 
tions with  a  syringe  or  bad  urethro-vesical  irrigations  were  responsible. 

The  anatomy  of  Cowper's  glands  and  their  ducts,  which  has  been  so 
well  studied  by  Hogge  of  Liege,  explains  the  pecuhar  features  of  this  locali- 
zation of  the  gonococcus.  Cowper's  gland  opens  by  means  of  a  relatively 
very  long  and  sinuous  duct,  which  soon  becomes  occluded  after  the 
gonococcus  has  invaded  it.  The  inflammation  gradually  reaches  the 
glandular  acini,  and  thus  a  closed  cavity,  filled  with  purulent  material,  is 
formed. 

Cowperitis,  which  has  been  well  studied  by  Lebreton,^  usually  super- 
venes during  the  third  or  fourth  week  of  the  attack  of  gonorrhea,  and  is 

^  When  this  fails,  it  becomes  necessary  to  resort  to  endoscopic  measures — elec 
trolysis,  cauterization,  etc.;  vide  Cliapter  XII.  (A.  ¥.). 

^  Hogge,  Anatomie  du  Pirinee,  VII.  Sess.  de  I'Ass.  FranQ.  d'Urologie,  Paris,  1903, 
p.  480. 

2  Lebreton,  Contribution  a  l' Etude  des  Glandes  Butho-Uretrcdes  de  et  leurs  Maladies 
(Paris,  Thesis,  1904). 


192  GONOKRHEA 

more  often  unilateral  than  bilateral.  Its  beginning  is  perfectly  painless, 
and  escapes  the  notice  of  the  patient.  The  specialist  who  is  consulted  for 
an  obstinate  and  rebellious  discharge,  should  always  consider  the  possi- 
bility of  an  infiammation  of  Cowper's  glands,  and  should  examine  them 
according  to  the  indications  laid  down  on  p.  102. 

When  a  small  swelling  is  present  on  one  side  of  the  urethral  bulb,  the 
diagnosis  of  cowperitis  is  easy.  But  if  the  swelling  is  of  a  more  diffuse 
character,  the  differential  diagnosis  between  this  condition  and  a  urinary 
abscess  is  much  more  difficult.  In  fact,  it  is  not  rare  to  find  a  urinary 
abscess  following  upon  a  cowperitis,  and  it  may  very  well  be  localized  in 
its  early  stage  to  one  side  of  the  urethra.  Later  on  the  abscess  reaches 
the  middle  fine,  and  assumes  characteristic  features  of  its  own.  An  abscess 
of  the  anal  margin  has  also  to  be  considered  for  purposes  of  differential 
diagnosis.  The  abscess  last  mentioned  lies  farther  back,  and  extends 
farther  to  either  side  of  the  anus. 

Clinically  one  meets  with  several  varieties  : 

1.  Cowperitis  with  Permeable  Duct. — When  the  duct  of  Cowper's  gland 
remains  patent — and  this  is  usually  the  case — the  contents  of  the  gland 
can  be  emptied  by  squeezing  the  organ  between  index  and  thumb.  They 
thus  find  their  way  through  the  duct  into  the  urethra,  and  thence  to  the 
outside.  These  cases  are  the  favourable  ones,  and  yield  rapidly  to  a  well- 
conducted  massage  treatment. 

It  is  best  to  combine  the  massage  with  urethro- vesical  irrigations  with 
potassium  permanganate  until  the  urine  collected  in  the  first  glass  has 
become  clear.  The  whole  passage  should  then  be  dilated  with  curved  steel 
sounds.  In  this  way  the  bulb  is  widened  out,  and  with  it  the  ducts  of 
Cowper's  glands.  Massage  gives  under  these  conditions  its  best  results, 
as  shown  in  the  following  two  instances : 

Case  1. — Gonorrheal  Cowperitis  of  Long  Standing  treated  by  Massage  of 
THE  Gland  and  Dilatation  of  the  Urethra  ;  Cure. 

A  man  of  thirty-four  was  sent  to  me  in  January,  1910,  by  Dr.  Emery.  He  suffered 
from  a  copious  discharge  which  contained  gonococci,  and  had  not  yielded  to  three 
months'  irrigations  with  potassium  permanganate. 

On  examination,  I  found  that  the  persistence  of  the  discharge  was  due  to  a  large, 
doughy,  inflamed,  and  painful  gland  of  Cowper,  which  yielded  plenty  of  pus  on  massage. 
I  at  once  resorted  to  massage  of  the  gland,  and  to  dilatation  with  curved  sounds  until 
No.  57  G  was  passed,  although  with  some  difficulty. 

In  June  the  urine  collected  in  the  first  glass  was  still  turbid  and  contained  thick 
masses  of  filaments,  and  the  massage  removed  a  great  quantity  of  heavy  filaments 
from  the  gland.  Considering  the  long  duration  of  the  illness,  I  feared  that  a  tuber- 
culous infection  of  the  gland  might  be  developing,  and  had  the  secretions  which  were 
massaged  from  the  gland  examined  bacteriologically. 

The  immediate  examination  of  the  specimen  and  inoculations  into  guinea-pigs  gave 
a  completely  negative  result.     I  therefore  continued  the  massage  treatment  ener- 


THE  COMPLICATIONS  OF  GONORRHEA  193 

getically,  with  the  result  that  the  patient  when  seen  again,  on  September  19, 1910,  had 
no  trace  of  a  discharge,  that  his  urine  was  clear,  and  that  the  massage  of  the  gland 
yielded  no  more  filaments. 

Case  2. — Gonorrheal  Cowperitis  treated  by  Massage  of  the  Gland  and 
Dilatation  of  the  Urethra  ;  Curb. 

A  youth  of  twenty-nine  was  sent  to  me  in  February,  1909.  He  had  a  great  deal  of 
discharge,  which  contained  a  considerable  number  of  gonococci.  His  right  Cowper's 
gland  was  much  enlarged  and  very  painful. 

Under  glandular  massage  and  irrigations  with  permanganate  considerable  improve- 
ment took  place,  but  as  soon  as  the  irrigations  were  discontinued  the  discharge 
reappeared. 

Professor  Legueu  was  therefore  consulted  on  March  27,  1909,  as  to  the  advisability 
of  excising  the  gland.  He  was  against  the  operation,  and  thus  the  same  treatment  was 
continued,  and  with  the  best  results.  It  was  necessary,  in  order  to  obtain  a  definite  cure, 
to  dilate  up  to  No.  60  G  with  curved  sounds,  and  then  with  Kollmann's  curved  dilator 
up  to  No.  37.  Through  this  treatment  Cowper's  gland  became  again  insensitive,  and 
a  definite  cure  was  obtained.  When  I  saw  the  patient  again  a  year  later,  he  had  no 
trace  of  any  disease ;  his  urine  was  perfectly  normal.  He  had  married,  and  no  untoward 
result  had  followed,  neither  for  him  nor  for  his  wife. 

2.  Cowperitis  with  Obstruction  of  the  Duct. — In  cases  of  this  kind  it 
is  impossible  to  empty  the  contents  of  the  inflamed  gland  into  the  urethra 
by  massage,  however  well  it  may  be  done.  They  are  therefore  very  obsti- 
nate and  difficult  to  cure. 

Several  varieties  are  met  with  :  either  the  cowperitis  takes  an  acute 
and  rapid  course  or  it  assumes  a  more  torpid  form. 

In  the  first  instance  the  patient  soon  notices  a  heavy  feeling  and  pain 
about  his  perineum.  In  a  short  time  a  swelling  of  the  size  of  a  cherry 
appears,  which  rapidly  suppurates  and  opens  spontaneously  on  the  skin. 
The  treatment  of  these  cases  is  simple:  an  immediate  incision  is  required 
in  order  to  evacuate  the  pus.  The  prognosis  is,  however,  not  favourable. 
A  fistulous  tract  often  remains,  which  may  develop  into  a  urinary  fistula — a 
condition  which  is  always  troublesome  and  difficult  to  cure. 

In  the  torpid  form  no  discharge  is  visible  as  long  as  the  urethra  is  irri- 
gated and  the  gland  massaged.  But  as  soon  as  this  treatment  is  discon- 
tinued, the  discharge  reappears  with  an  exasperating  tenacity. 

In  these  cases,  in  which  glandular  massage,  combined  or  not  with  dila- 
tation of  the  urethra  by  means  of  curved  metal  sounds,  is  of  no  avail, 
Cowper's  gland  should  be  attacked  with  the  knife.  One  should  not  be 
content  with  incising  it,  but  should  resort  to  extirpation,  as  in  the  case 
about  to  be  described  : 

A  youth  of  twenty-two  and  a  half  was  sent  to  me  in  November,  1906,  by  Dr.  Cheur- 
lot.  He  was  suffering  from  a  copious  discharge  -which  contained  gonccccci.  The  local 
examination  showed  the  presence  of  a  small  swelling  to  the  left  side  of  the  bulb,  which 
was  of  the  size  of  a  cherry  and  was  very  tender. 

13 


194  GONOREHEA 

Dilatation  and  massage  Mere  resorted  to,  and  after  eacli  visit  the  patient  showed 
considerable  improvement.  However,  as  soon  as  this  treatment  was  left  off,  the 
discharge  reappeared. 

These  perpetual  recurrences  decided  me  to  advise  the  complete  removal  of  the 
diseased  Cowper's  gland.  Professor  Segond  performed  the  operation,  which  was  fol- 
lowed by  a  complete  cure. 

This  extirpation  treatment  appears  to  be  the  best  therapy  for  this  con- 
dition, and  is  frequently  indicated,  as  one  has  to  protect  the  patients  against 
a  tuberculous  infection  of  Cowper's  gland,  which  not  infrequently  super- 
venes when  the  gonorrheal  infection  is  subsiding. 

Primary  tuberculosis  of  Cowper's  gland  is  well  known  to  occur  since 
the  researches  of  Englisch,^  Tapret,^  Couillard  and  Despres,^  Hartmann  and 
Lecene,^  and  supervenes  in  the  following  manner:  The  gonococcus  invades 
Cowper's  gland,  damages  it,  and  lessens  its  resistance.  The  tubercle 
bacillus  then  grafts  itself  on  the  weakened  gland,  and  overpowers  it. 

The  treatment  should  be  removal  of  the  gland.  For  the  operation 
the  patient  is  put  into  the  lithotomy  position,  and  a  curved  incision  is  made 
from  one  tuberosity  of  the  ischium  to  the  other,  the  convexity  being  directed 
forwards — i.e.,  the  same  incision  as  for  perineal  prostatectomy.  When  the 
most  anterior  fibres  of  the  anal  sphincter  have  been  divided,  the  rectum 
is  separated  and  drawn  backwards.  By  means  of  retractors  one  can  then 
bring  the  membranous  urethra  into  view,  and  one  follows  it  downwards  along 
its  sides  to  the  angle  formed  by  the  bulb  and  the  urethra,  in  which  Cowper's 
gland  lies.  In  order  to  have  a  free  access  to  it,  the  superficial  transversus 
perinei  muscle  may  be  divided.  If  perineal  fistulse  have  supervened  owing 
to  a  protracted  cowperitis,  they  should  be  curetted  or  destroyed  by  means 
of  the  thermo- cautery.  It  is  essential  to  remove  the  gland  as  completely 
as  possible,  and  also  any  diverticula  which  may  be  present;  otherwise  the 
wound  will  not  heal,  and  everlasting  fistulse  are  apt  to  follow. 


Prostatitis. 

The  prostate  is  hable  to  two  different  forms  of  inflammation  if  it  is 
infected  during  an  attack  of  gonorrhea.  Its  inflammation  may  be  either 
acute  or  chronic. 

^  Englisch,  "  tJber  Tuberkulose  Urethritis  and  Peri-Urethritis  :  Zui-  Extirpation 
der  Cowperschen  Driisen,"  reference  in  Ceniralh.  /.  Chir.,  1891,  p.  819,  and  Centralb. 
/.  Harnlcr.,  1894,  p.  371. 

15  2  Tapret,  "  Etude  sur  la  Tuberculose  Urinaire,"  Arch.  Oin.  de  Mid.,  Paris,  1878, 
vol.  i.,  p.  513,  and  vol.  ii.,  pp.  57  and  4.05. 

3  Couillard,  Contribution  a  VEtude  des  Affections  de  la  Glande  de  Cowper  (Paris, 
Thesis,  1876),  p.  31. 

*  H.  Hartmann  and  Lecene,  "  La  Tuberculose  de  la  Glande  de  Cowper,"  in  Travauz 
de  Chirurgie  Anatomique,  Paris  (Steinheil),  1903,  p.  118. 


THE  COMPLICATIONS  OF  GONORRHEA  195 

Acute  Prostatitis. — According  to  Montagnin  (1885)  and  Eraud  (1886), 
70  per  cent,  of  all  cases  of  gonorrhea  suffer  from  prostatitis.  The  chief 
cause  of  this  comphcation  is  to  be  found  in  clumsy  urethral  injections, 
which  are  always  harmful.  Other  causes  are  sexual  excess,  masturbation, 
fatigue,  excessive  exercise,  and  long  journeys  by  carriage  or  by  rail. 

If  the  inflammation  is  confined  to  the  crypts  of  the  gland,  and  if  the 
prostatic  parenchyma  remains  healthy,  one  has  to  deal  with  glandular 
'prostatitis,  which  is  a  mild  form.  On  other  occasions  the  excretory  ducts 
of  the  infected  glandules  are  obliterated,  and  the  latter  become  distended. 
This  condition,  which  is  frequently  accompanied  by  a  marked  periglandular 
inflammation,  is  called  phlegmonous  interstitial  or  parenchymatous  pros- 
tatitis, and  usually  leads  to  the  formation  of  an  acute  prostatic  abscess. 
An  abscess  of  this  kind  usually  bursts  into  the  urethra,  but  it  may  also 
open  into  the  rectum  or  some  other  neighbouring  structure.^  It  is  not 
infrequently  accompanied  by  a  periprostatitis  by  diffusion,  as  the  inflam- 
mation spreads  into  the  prerectal  cellular  tissue.  Large  collections  of  pus 
pointing  towards  the  perineum  and  the  pelvis  are  then  hkely  to  be  found. 
The  infection  of  the  periprostatic  cellular  tissue  can  also  be  brought  on  by  a 
direct  spreading  along  the  contiguous  tissues  or  through  the  blood-stream 
or  through  the  lymphatics. 

Glandular  prostatitis  is  asymptomatic — hence  the  necessity  of  looking 
out  for  it  in  every  case  of  gonorrhea,  and  of  massaging  the  prostate. 

In  phlegmonous  prostatitis  general  symptoms  are  present,  such  as 
fever,  which  may  rise  to  39°,  40°,  and  even  41°  C. ;  tenesmus  and  dysuria 
which  are  often  highly  troublesome.  Retention  of  urine,  owing  to  the  swell- 
ing of  the  prostate,  is  not  rare.  In  these  cases  palpation  per  rectum  allows 
one  to  make  the  diagnosis  by  showing  the  prostate  to  be  enlarged  and 
painful.  The  passing  of  a  catheter  is  always  very  unpleasant  in  these  cases, 
and  not  without  danger.  One  should  reserve  this  measure  for  very  urgent 
cases  in  which  the  retention  is  complete. 

The  treatment  differs  according  to  the  type  of  lesion  present.  The 
glandular  form  is  treated  by  means  of  permanganate  irrigations  combined 
with  prostatic  massage. 

The  treatment  of  phlegmonous  prostatitis  depends  on  the  stage  of  the 
illness.  In  the  beginning,  before  pus  has  collected,  an  antiphlogistic  treatment 
is  indicated,  such  as  rest  in  bed,  soothing  drinks,  suppositories  containing 
morphia  and  belladonna,  hot  rectal  irrigations,  etc.  Once  the  pus  has 
collected,  it  should  be  given  an  outlet. 

^  In  statistics  collected  by  Segond  (1880),  the  prostatic  abscesses  opened  sixty-four 
times  into  the  urethra ;  forty-three  times  into  the  rectum ;  fifteen  times  in  the  perineum; 
eight  times  into  the  ischio-rectal  fossa;  three  times  into  the  groin;  twice  through  the 
obturator  foramen;  once  at  the  umbilicus;  once  through  the  great  sacro-sciatic  notch; 
once  at  the  false  ribs;  once  into  theperitDneum;  once  iiito  the  cavity  of  Retzius  (A.  P.). 


196  GONOEEHEA 

The  question  how  one  should  deal  with  acute  prostatic  abscesses  has 
been  discussed  in  1907  at  the  meeting  of  the  French  Urological  Association, 
and  Dr.  Oraison's  report  shows  that  there  are  three  methods  of  unequal 
value  for  coping  with  this  affection  : 

1.  The  opening  of  the  abscess  from  within  the  urethra  by  massaging 
the  gland  and  repeated  lavage  is  only  feasible  for  very  small  abscesses 
which  lie  immediately  under  the  surface  of  the  urethral  mucosa. 

2.  The  opening  of  the  abscess  'per  rectum  gives  excellent  results  in  most 
cases.  Oraison  has  a  preference  for  this  method,  because  it  is  very  simple, 
safe,  and  rapid.     One  uses  for  it  a  ball-pointed  knife. 

3.  The  opening  of  the  abscess  by  the  perineal  route  is  more  complicated? 
and  is  more  apt  to  be  followed  by  untoward  results,  such  as  the  formation 
of  a  fistula  or  injury  to  the  ejaculatory  ducts.  But,  as  has  been  well  pointed 
out  by  Professor  Albarran,  it  has  the  great  advantage  of  being  the  cleanest 
method,  and  of  allowing  one  to  deal  thoroughly  with  all  the  various  collec- 
tions of  pus  which  may  be  present,  and  of  thus  insuring  a  complete  cure.. 

This  last  method  is  evidently  the  most  suitable  one  for  large  prostatic 
abscesses  which  require  to  be  opened  up  as  freely  as  possible  once  they  are 
diagnosed. 

Chronic  Prostatitis. — Chronic  prostatitis,  of  which  Le  Fiir  has  given 
an  excellent  account,  is  one  of  the  commonest  complications  of  gonorrhea. 
Its  onset  is  usually  insidious,  and  therefore  examination  and  massage  of 
the  prostate  should  not  be  omitted  in  any  case  of  gonorrhea  {vide  p.  104). 

The  presence  of  a  chronic  inflammation  of  the  prostate  is  always  to  be 
expected  when  the  discharge  is  scanty,  and  when  the  third  and  fourth  glasses 
contain  filaments.  The  diagnosis  is  clinched  by  rectal  palpation  and  massage 
of  the  gland,  as  described  above  {vide  p.  105). 

The  treatment  of  chronic  prostatitis  comprises  two  main  phases: 

1.  In  the  beginning,  when  all  four  glasses  are  turbid,  when  the  gland  is 
still  very  tender  on  rectal  palpation,  and  yields  a  considerable  amount  of 
purulent  debris  on  massage,  the  only  direct  treatment  admissible  is  massage 
of  the  gland  {vide  Chapter  XII.),  combined  with  hot  permanganate  irri 
gations.  At  the  same  time,  an  antiphlogistic  treatment  should  be 
instituted,  consisting  of  hot  rectal  injections,  hot  fomentations  on  the 
perineum,  plenty  of  fluid  by  the  mouth,  urotropin  internally,  etc. 

Very  often  good  results  are  obtained  from  one  of  the  following  supposi- 
tories : 

1.  Mercury  ointment     . .  . .  . .     0-05  gramme. 


Cocoa  butter  . . 

Potassium  iodide 

Cocoa  butter 

Ichthyol 

Extract  of  belladonna 

Cocoa  butter 


q.s.  for  a  suppository. 

0-50  gramme. 

q.s.  for  a  suppository. 

0-10  gramme. 

0-015 

q.s.  for  a  suppository. 


THE  COMPLICATIONS  OF  GONORRHEA  197 

2.  When  the  urine  has  become  clear,  the  massage  and  the  irrigations 
should  be  combined  with  dilatation  by  means  of  curved  steel  sounds.  This 
latter  treatment,  however,  requires  to  be  carried  out  with  great  caution, 
as  it  is  apt  to  set  up  an  orchitis  if  done  carelessly.  Gentle  and  methodical 
dilatations  usually  lead  to  a  very  rapid  improvement.  Once  No.  60  G 
has  been  passed,  it  is  advisable  to  continue  the  dilatation  by  means  of 
Frank's  irrigating  dilator  or  a  similar  instrument. 

Lastly,  in  order  to  make  certain  that  the  patient  is  cured,  and  that  no 
trace  of  inflammation  is  left  in  the  prostatic  glands  and  in  the  urethra, 
urethroscopy  of  the  posterior  urethra  should  be  resorted  to,  and  appropriate 
local  interventions  should  be  carried  out  if  necessary. 

It  is  indispensable  to  submit  the  patients  who  are  suffering  from  chronic 
prostatitis,  to  the  control  of  the  urethroscope.  The  massage  of  the  gland 
per  rectum  improves  the  posterior  part  of  the  gland,  but  it  has  no  effect 
on  the  portion  which  is  situated  in  front  of  the  urethra,  and  it  is  also  in- 
adequate when  the  orifices  of  the  prostatic  glandules  are  obstructed.  Where 
it  fails  in  combination  with  dilatation,  endo-urethral  interventions  have  to 
be  resorted  to  in  order  to  obtain  a  cure. 

The  urethroscope  allows  one  to  diagnose  the  openings  through  which 
the  pus  oozes,  and  it  enables  one  to  enlarge  and  to  lay  open  the  fistulse 
present  by  means  of  the  cautery,  and  to  insure  a  proper  drainage. 

The  portions  of  the  prostate  which  most  often  require  interventions 
of  this  nature,  are  situated  on  the  lower  wall  behind  the  verumontanum, 
in  the  region  of  the  prostatic  fossette,  and  in  the  lateral  grooves  to  either 
side  of  the  verumontanum,  which  are  a  favourite  site  for  the  openings 
of  fistulse. 

By  urethroscoping  the  posterior  urethra  and  massaging  the  prostate 
per  rectum  simultaneously,  the  openings  through  which  the  pus  escapes, 
can  be  ascertained  by  sight.  One  then  brings  the  point  of  the  electric 
cautery  up  to  them,  and  enlarges  them  as  much  as  possible. 

When  several  openings  have  been  treated  in  this  way,  it  happens  that 
one  big  hole  is  formed,  leading  to  a  vast  cavity,  which  is  now  easily  accessible 
and  can  be  disinfected  by  swabbing  it  with  mounted  swabs  which  are  satu- 
rated with  some  antiseptic  solution. 

A  most  interesting  instance  was  a  man  of  forty-seven,  who  had  had 
gonorrhea  twenty-two  years  previously,  when  he  was  twenty-five.  His  urine 
was  turbid,  and  contained  a  great  amount  of  heavy  purulent  flakes,  and 
by  massage  a  good  deal  of  pus  could  be  squeezed  out  of  the  prostate. 

With  the  urethroscope  one  could  see  that  the  prostatic  fossette  was 
converted  into  a  regular  sponge,  which  was  drenched  with  pus.  Of  special 
importance  was  the  fact  that  pus  oozed  out  of  an  orifice  situated  in  the 
groove  on  the  right  side  of  the  verumontanum,  when  the  finger  in  the  rectum 


198  GONOERHEA 

pressed  on  the  left  lobe  of  the  prostate.  I  thus  had  to  conclude  that  the 
parenchyma  of  the  prostate  was  riddled  with  fistulous  tracts.  A  series 
of  punctures  with  the  cautery  was  made  in  a  transverse  direction,  and  thus 
a  regular  trench  was  formed  behind  the  verumontanum.  The  exposed 
cavity  was  gradually  enlarged  and  cleansed  with  antiseptics.  Once  it 
was  properly  laid  open,  the  pus  became  gradually  less  thick,  the  secretions 
were  more  fluid,  and  the  urine  became  clearer  every  day. 

The  therapeutic  result  was  brilliant,  and  shows  what  can  be  done  by 
endo-urethral  interventions  in  cases  of  prostatic  inflammation  which  seemed 
to  be  incurable.^ 


Gonorrheal  Inflammation  of  the  Testicle. 

The  term  "  gonorrheal  orchitis,"  so  frequently  used,  is  a  bad  one,  for  in 
most  cases  the  epididymis  alone  is  involved.  It  is  therefore  better  to  speak 
of  epididymitis. 

This  extremely  frequent  complication  is  met  with  in  about  25  per  cent, 
of  all  cases.  It  comes  on  during  the  third,  fourth,  or  fifth  week,  and  is 
directly  due  to  the  gonococcus,  although  the  presence  of  this  organism 
has  been  seldom  demonstrated. 

Walter  Collan^  failed  to  find  any  gonococci  in  the  pus  withdrawn  by 
puncture  from  an  epididymitis  which  complicated  a  gonorrhea  of  two  and 
a  half  months'  standing,  when  he  examined  it  under  the  microscope.  But 
he  obtained  a  positive  result  with  his  cultures  on  ascites-agar  which  showed 
several  typical  colonies. 

Similar  observations  had  been  published  previously  by  Routier  and  by 
G-rosz. 

The  first  symptom  of  epididymitis  is  usually  a  heavy  feeling  .about  the 
scrotum,  and  on  palpation  the  tail  of  the  epididymis  is  found  to  be  somewhat 
enlarged.  The  pain  which  comes  on  subsequently,  is  often  so  acute  as  to 
make  the  patient  moan  and  shriek.  As  a  rule,  it  lasts  three  to  five  days. 
It  then  diminishes  in  intensity,  and  disappears  fairly  rapidly.  The  testicle 
is  always  swollen ;  the  skin  over  it  is  red,  hot,  and  tense.  Behind  the  testicle 
which  has  retained  its  pecuhar  sensation,  a  hard  mass  is  to  be  felt  which 
is  very  tender  on  pressure.  A  certain  degree  of  hydrocele  is  very  commonly 
present.  The  general  health  is  always  affected,  and  there  is  fever,  rising 
to  100°  or  102°  F.,  which  lasts  about  four  to  five  days,  and  then  gradually 
disappears.     The  duration  of  the  illness  is  from  two  to  three  weeks  on  the 

^  Vide  also  in  this  connection  the  interesting  case  published  by  Dr.  Desvignes  of 
Limoges  ("De  laNecessite  de  Urethroscopie  dans  le  Diagnostic  de  I'Uretrite  Posteri- 
eure  Chronique,"  in  La  CUnique,  1911). 

2  Walter  CoUan,  Wien.  Klin.  Woch.,  1897,  No.  48,  p.  1061. 


THE  COMPLICATIONS  OF  GONORRHEA  199 

average.  As  a  rule,  the  inflammation  subsides  without  leaving  any  trace; 
occasionally,  however,  a  nodule  remains  in  the  tail  of  the  epididymis,  or 
the  other  testicle  may  become  infected.  The  prognosis  is  good,  and  a  cure 
is  usually  observed  after  two  to  three  weeks.  The  dark  point  is  the  func- 
tional trouble  which  may  follow.  In  cases  of  bilateral  epididymitis  the 
spermatozoa  may  disappear  completely,  and  thus  render  the  patient  unfit 
to  beget  children. 

Medical  Treatment  of  Gonorrheal  Epididymitis. — Complete  rest  in  bed 
and  the  raising  of  the  scrotum  to  the  level  of  the  abdomen  are  essential. 
A  board  fitted  with  a  suitable  notch  is  one  of  the  best  appliances  for  the 
purpose.  It  is  also  well  to  make  use  of  soothing  local  measures,  such  as 
hot  fomentations.  The  application  of  an  ice-bag  to  the  parts  is  one  of  the 
best  means  for  the  relief  of  the  pain,  but  care  should  be  taken  to  surround 
it  by  flannel  or  by  wool  before  putting  it  on  the  parts. 

Hot  applications  are  also  of  value,  and  it  is  a  good  plan  to  use  them  in 
alternation  with  the  ice-bag.  This  combination  is  most  effective  in  re- 
ducing the  pain.     For  the  continuous  application  of  heat  to  the  scrotum 

1  have  devised  a  small  sachet  which  is  made  of  a  fabric  which  conducts 
electricity  well.  This  apparatus  is  connected  through  a  resistance  with 
the  main,  and  gives  an  even  heat  to  the  scrotum. 

The  pain  diminishes  markedly  and  rapidly  under  this  treatment,  but 
the  duration  of  the  illness  is  not  shortened,  nor  is  the  fever  influenced  in 
any  way. 

Bettmann^  treats  gonorrheal  epididymitis  by  means  of  salicylates.  He 
pours  6  or  8  c.c.  of  a  mixture,  composed  of  1  part  of  methyl  salicylate  and 

2  parts  of  olive- oil,  on  a  compress  made  of  ordinary  wool,  and  applies 
it  to  the  scrotum.  The  latter  and  its  dressings  are  then  covered  with  india- 
rubber  paper  and  put  into  a  well-padded  suspensory  bandage.  Firm  pres- 
sure is  made  on  the  scrotum  in  this  way. 

Picot^  advises  the  use  of  sodium  salicylate  in  the  dose  of  4  grammes 
per  day,  taken  in  four  cachets  of  1  gramme  each.  This  treatment  is 
persevered  with  for  eight  to  ten  days,  during  which  the  patient  is  without 
pain. 

Sodium  salicylate  seems  thus  to  be  an  excellent  remedy  for  gonorrheal 
epididymitis. 

Du  Castel  ^  used  methyl  chloride,  which  he  sprayed  daily  upon  the  diseased 
part  of  the  scrotum,  or  which  he  applied  by  means  of  a  piece  of  wool  im- 
pregnated with  it.     Ethyl  chloride  may  be  used  instead. 

1  Bettmann,  Iliinch.  Med.  Woch.,  1899,  No.  38.  p.  1233. 

2  Picot,  Paris,  Thesis,  1899. 

3  Du  Castel,  Soc.  de  Therap.,  January  12,  1S9S. 


200  GONORRHEA 

Professor  Petrini  Galatz^  recommends  the  use  of  the  following  ointments 
in  epididymitis: 

Vaseline 
Ichthyol 
Guaiacol 


Or— 


Lead  iodide 
Cold  cream 


30  grammes. 
4        „ 
2 

2  grammes. 
30        „ 

The  indurated  nodules  of  epididymitis  have  been  treated  by  means  of 
so-called  "  melting  ointments,"  which  probably  owe  their  name  to  the  fact 
that  they  melt  when  they  come  into  contact  with  the  skin  (Fournier). 
They  have  no  effect  on  the  inflammation. 

Surgical  Treatment  of  Acute  Gonorrheal  Epididymitis. — Of  late,  the 
surgical  treatment  of  acute  gonorrheal  epididymitis,  which  was  once  upon 
a  time  recommended  by  Pirogoff  and  Vidal  de  Cassis,  has  again  been 
advocated. 

Baermann^  advises  the  puncture  of  the  epididymis  in  acute  epididymitis 
of  gonorrheal  origin;  the  local  pain  and  the  feeling  of  tension  disappear 
rapidly  and  permanently.  The  fever  is  soon  checked,  and  subsides  com- 
pletely. This  intervention  is  often  of  the  greatest  value  if  done  properly. 
So  far  puncture  of  the  epididymis  has  not  given  rise  to  any  accidents ;  its 
chief  disadvantage  is  that  it  is  painful. 

Dr.  Bazet^  of  San  Francisco  makes  a  practice  of  treating  acute  epi- 
didymitis by  means  of  epididymotomy.  He  incises  the  cavity  of  the  epi- 
didymis by  an  incision  which  is  about  an  inch  long,  and  runs  parallel  with  the 
axis  of  the  organ.  If  any  pus  is  present,  he  punctures  the  various  nodules, 
and  stitches  the  walls  of  the  epididymis  to  the  skin.  In  a  week  the  wound 
is  healed,  and  the  patient  is  allowed  to  get  up  some  time  between  the  fourth 
and  seventh  day. 

The  treatment  of  epididymitis  by  means  of  aspirator y  puncture'^  is  a 
modification  of  the  simple  puncture  by  means  of  the  knife.  Dr.  Ernst  ^ 
uses  a  sterilized  syringe  with  a  very  sharp  needle.  He  thrusts  the  needle 
through  the  skin  of  the  scrotum  into  the  substance  of  the  epididymis  as 
far  as  ^  to  f  inch,  and  then  withdraws  it,  gently  aspirating  at  the  same  time. 
This  httle  operation  is  carried  out  without  any  anesthetic. 

As  a  rule,  very  little  fluid  is  withdrawn.  The  effect  of  the  aspiration 
becomes  manifest  by  an  almost  immediate  relief  of  pain,  and  within  twenty- 
four  hours  the  swelling  of  the  epididymis  has  gone  down  considerably. 

^  Petrini  Galatz,  Presa  Medicala  Romana,  June  1,  1902,  pp.  161,  166. 

2  Presse  Medicate,  1903,  p.  730. 

2  Bazet,  American  Urological  Association,  January  16,  1906. 

*  Jour,  de  Med.  et  de  Chir.  Prat.,  May  10,  1910,  p.  349,  No.  22,850. 

'^  Ernst,  Berl.  Klin.  Woch.,  March  15,  1909. 


THE  COMPLICATIONS  OF  GONORRHEA  201 

The  aspiratory  puncture  eases  the  sufferings  of  the  patients  so  promptly, 
and  shortens  the  course  of  the  infection  to  such  an  extent,  that  it  may  be 
recommended  as  the  most  suitable  treatment  for  hospital  practice. 

WilUam  Belfield^  has  conceived  a  prophylactic  treatment  which  is 
intended  to  safeguard  against  epididymitis  and  the  resulting  obstruction 
of  the  vas  deferens.  He  exposes  this  structure,  under  local  anesthesia, 
through  an  incision  about  |  inch  in  length,  and  opens  it  along  its  axis. 
He  then  introduces  into  its  lumen  the  blunt  needle  of  a  hypodermic  syringe, 
and  injects  some  medicated  fluid,  which  runs  through  the  vas  into  the 
seminal  vesicle.  At  each  end  of  the  incision  a  piece  of  fishing-gut  is  passed 
into  the  duct  about  J  inch,  and  brought  again  to  the  skin,  where  it  is  tied 
loosely.  This  knot  serves  as  guide  for  the  needle  when  the  daily  irrigations 
are  given,  and  preserves  the  lumen  of  the  duct  during  cicatrization. 

BeLfield  claims  to  have  treated  six  cases  in  this  fashion  with  the  greatest 
success. 

Dr.  Hagner^  describes  his  own  operative  procedure  as  follows:^  An  in- 
cision 2^  to  4  inches  long  is  made  through  the  various  layers  of  the  scrotum 
and  through  the  tunica  vaginalis  at  the  junction  of  testicle  and  epididymis. 
The  organ  is  brought  to  the  surface,  and  a  series  of  punctures  are  made  in 
the  epididymis.  If  pus  escapes  from  one  of  these,  the  hole  is  immediately 
enlarged,  a  small  drainage-tube  is  inserted,  and  the  purulent  cavity  is 
washed  with  a  1  :  1,000  solution  of  perchloride  of  mercury,  followed  by 
)  normal  saline.  The  wound  in  the  scrotum  is  then  sewn  up  except  at  its 
lower  angle,  where  a  gauze  drain  is  inserted. 

The  good  results  obtained  by  this  method  have  led  Dr.  Hagner  to  formu- 
late the  following  conclusions : 

1.  The  surgical  treatment  of  acute  gonorrheal  epididymitis  is  rational 
and  without  danger. 

2.  The  inflammation  subsides  much  more  rapidly  under  this  treatment 
than  under  any  other  therapy. 

3.  The  immediate  effect  of  the  intervention  is  excellent  as  far  as  pain  is 
concerned. 

4.  The  chances  of  obliteration  of  the  epididymis  and  of  subsequent 
atrophy  of  the  testicle  are  lessened. 

Dr.  Paul  Asch,"^  of  Strassburg,  advocates  injections  of  electrargol  into 
the  lesions  of  the  epididymis,  thus  following  Hamonic's  example.-'' 

^  William  Belfield  of  Chicago,  Urological  Society,  October  25,  1906. 
2  Hagner,    "The    Operative   Treatment   of    Gonorrheal   Epididymitis,"    Medical 
Record,  October  13,  1906,  p.  565. 

^  Vide  Kendirdjy,  La  Clinique,  February  15,  1907. 
*  Paul  Asch,  Zeits.f.  Urol.,  vol.  v.,  1911,  p.  87. 
f'  Hamonic,  Ass.  FrariQ.  d'Urol.,  1908,  p.  232. 


202  GONORRHEA 

Asch's  technique  is  simple  :  The  skin  is  disinfected  with  tincture  of 
iodine,  and  1  to  2  c.c.  of  electrargol  are  injected  into  the  inflamed  epididymis 
by  means  of  a  syringe  fitted  with  a  very  fine  needle.  If  necessary,  this 
treatment  should  be  repeated  once  or  twice  at  intervals  of  twenty-four 
hours.     More  than  three  injections  are  seldom  required. 

The  results  obtained  with  this  treatment  are  the  following:  In  very  early 
cases  in  which  the  neighbouring  parts  were  not  infiltrated,  one  injection  was 
usually  sufficient  (fifteen  times  out  of  eighteen)  to  abort  the  attack,  and  a 
restitutio  ad  integrum  took  place  within  one  to  three  days.  No  indurations 
are  left  behind,  and  the  testicle  retains  its  function.  This  fact  was  proved 
by  five  cases  in  which  the  other  epididymis  had  been  obliterated  by  a  previous 
illness. 

In  three  out  of  the  eighteen  cases  a  second  injection  was  necessary  before 
a  complete  cure  could  be  obtained.  When  the  soft  parts  are  infiltrated, 
two  or  three — seldom  more — injections  are  required.  The  cure  takes  place 
in  three  to  eight  days.  Sometimes,  however,  fully  two  to  three  weeks 
elapse  before  the  resorption  is  complete,  and  it  should  be  assisted  in  these 
cases  by  fomentations  and  hot  sitz-baths.  In  all  instances  the  resolution 
was  ultimately  complete,  and,  as  far  as  one  could  tell,  the  functional  char- 
acter of  the  testis  was  normal. 

The  only  drawback  to  this  method  is  a  temporary  increase  of  tension 
and  of  pain,  especially  when  infiltration  is  present.  But  in  a  few  hours 
this  discomfort  is  followed  by  a  feeling  of  relief. 

Collargol  is  less  satisfactory  than  electrargol;  it  appears  to  be  less  homo- 
geneous, less  pure,  and  less  endowed  with  catalytic  properties. 

The  electrargol  treatment  is  held  by  Asch  to  be  the  treatment  of  choice 
for  acute  epididymitis.  The  sooner  the  injection  is  given,  the  more  rapid 
is  the  cure.  In  quite  early  cases  the  electrargol  treatment  is  an  abortive 
measure,  but  even  when  the  surrounding  tissues  are  infiltrated  and  edema- 
tous, a  complete  anatomical  and  physiological  cure  may  be  expected  from 
this  treatment. 

One  should  not  forget  that  the  effect,  the  epididymitis,  is  not  the  only 
condition  which  requires  treatment  in  these  cases.  Its  cause — the  in- 
flammation of  the  posterior  urethra — also  demands  attention.  During  the 
acute  stage  it  is  therefore  right  to  prescribe  plenty  of  fluid,  and  to  start 
irrigations  with  a  solution  of  potassium  permanganate,  1  :  4,000,  as  soon 
as  the  fever  has  subsided.  In  this  way  excellent  results  are  obtained,  and 
the  period  of  treatment  is  much  shortened. 

Moreover,  it  is  necessary  in  all  cases  of  epididymitis  to  examine  the 
condition  of  the  seminal  vesicles.  In  most  cases  these  organs  are  inflamed, 
and,  once  the  epididy mo- orchitis  is  subsiding,  it  is  advisable  to  combine 
the  irrigations  with  massage  of  the  vesicles.     In  this  way  the  resolution 


THE  COMPLICATIONS  OF  GONORRHEA  203 

is  more  rapid,  and  the  nodules  which,  so  frequently  follow  upon  an  acute 
epididymitis  disappear  much  more  quickly. 

Sterility  Supervening  upon  Double  Epididymo-Orchitis.— When  both 
testicles  have  been  involved  in  the  gonorrheal  inflammation,  indurated 
nodules  may  persist  in  the  tail  of  the  epididymis  for  a  long  time— often  many 
months,  or  even  years — after  the  inflammation  has  subsided  and  passed 
off.  They  consist  of  fibrous  tissue  formed  within  and  around  the  canal  of 
the  epididymis,  and  may  constrict  the  cavity  of  this  organ  to  such  an  extent 
that  the  testicle  is  shut  off  from  the  seminal  vesicle.  The  epididymis  is 
thus  obstructed,  and  it  is  easy  to  understand  that  the  spermatozoa  can  no 
longer  pass,  and  are  wanting  in  the  sperma  ejaculated.  Experience,  how- 
ever, shows  that  this  obliteration  does  not  always  take  place,  not  even  in 
cases  of  double  epididymitis.  When  one  meets  with  instances  of  this 
kind,  one  should,  therefore,  not  be  too  rash  in  proclaimimg  their  complete 
sterility,  not  even  if  a  microscopic  examination  of  the  ejaculated  material 
seems  to  corroborate  this  view.  One  single  microscopic  examination  of 
this  kind  is  quite  inadequate. 

It  is  only  natural  that  attempts  should  have  been  made  to  overcome 
the  obhteration  of  the  sperm  channel  by  means  of  a  plastic  operation,  and 
for  this  purpose  one  has  advocated  to  exclude  the  constricting  fibrous  node 
in  the  epididymis  by  anastomosing  the  body  of  Highmore  with  the  vas 
deferens. 

Unfortunately,  the  practical  results  obtained  do  not  appear  to  come 
up  to  the  expectations  founded  on  this  theoretically  hopeful  and  sound 
measure,  as  one  of  my  cases  shows  : — • 


Double  Obchitis;  Absence  of  Spermatozoa;  Unilateral  Anastomosis  of  the 
Vas  Deferens  to  the  Body  of  Highmore;  Operative  Success,  but  Complete 
and  Permanent  Absence  of  Spermatozoa. 

A  man  of  thirty -four  acquired  an  attack  of  gonorrhea  towards  the  end  of  1904, 
which  was  complicated  by  prostatitis  and  double  orchitis.  In  1906  all  discharge  had 
disappeared,  but  there  were  two  very  hard  nodules  left  in  each  epididymis.  On  two 
occasions  examination  of  the  sperma  showed  total  absence  of  spermatozoa,  and  I 
therefore  sent  him  to  Professor  Pierre  Delbet,  at  the  Laennec  Hospital,  who  anasto- 
mosed the  right  vas  to  the  right  body  of  Highmore.  The  operation  was  completely 
successful,  and  the  patient  left  hospital  at  an  early  date. 

When  I  saw  the  patient  again,  three  years  later,  the  testicle  which  had  been  operated 
on  was  quite  smooth  and  regular,  and  of  normal  shape  and  size.  The  left  testicle,  on 
the  other  hand,  which  had  not  been  operated  on,  still  presented  a  big  induration  at 
the  epididymis.     Examination  of  the  sperma  showed  no  trace  of  any  spermatozoa. 

One  thus  had  to  conclude  that,  despite  a  successful  operation,  the 
spermatozoa  did  not  reappear  in  the  sperma  within  three  years. 

However,  it  would  hardly  be  fair  to  condemn  the  operation  on  the 


204  GONOERHEA 

strength  of  this  single  unsuccessful  case.     It  is  quite  possible  that  a  large 
material  would  yield  a  certain  number  of  successes. 

One  should,  however,  not  forget  that  in  cases  of  double  orchitis  the 
prostate  and  the  seminal  vesicles  are  chronically  inflamed  as  well  as  the 
epididymis.  It  is  therefore  very  difficult  to  tell  exactly  to  what  extent 
each  of  these  various  organs  is  responsible  for  the  sterility.  A  chronic 
inflammation  of  the  vas  and  of  the  prostate  may  very  well  alter  their 
secretions  sufficiently  to  render  them  an  unsuitable  medium  for  the 
spermatozoa. 

Gonorrheal  Vesiculitis  (Spermato-Cystitis). 

Spermato-cystitis  is  a  common  complication  of  gonorrhea.  It  may  be 
unilateral  or  bilateral,  and  is  always  a  tedious  and  serious  complaint 
which  cannot  be  cured  easily. 

The  diagnosis  of  spermato-cystitis  is  relatively  seldom  made,  consider- 
ing the  commonness  of  this  affection.  The  reason  of  this  is  to  be  found 
in  the  vagueness  of  the  symptoms.  It  is  therefore  always  necessary  to 
explore  the  seminal  vesicles  in  cases  of  gonorrhea. 

Its  causation  is  somewhat  obscure.  There  is,  however,  no  doubt  that 
intercourse  during  an  acute  attack  of  gonorrhea  is  a  chief  etiological 
factor. 

As  a  rule,  vesiculitis  is  accompanied  by  a  trifling  discharge.  Very  often 
there  is  nothing  but  a  little  moisture  about  the  meatus,  or  a  drop  in  the 
morning,  and  in  some  cases  there  is  no  discharge  at  all.  There  may  be  some 
vague  pains  about  the  perineum  or  the  lower  abdomen  or  the  loins.  They 
are  usually  more  marked  during  defecation,  and  radiate  along  the  urethra, 
the  glans,  the  testicles,  and  sometimes  also  to  the  kidneys.  They  may  assume 
the  character  of  "  colic  "  (vesicular  cohc),  and  be  mistaken  for  an  attack 
of  appendicitis  or  of  renal  or  ureteric  colic.  Reliquet^  studied  them  long 
ago,  and  found  them  to  be  cramp-like,  and  to  start  in  the  deep  part  of  the 
urethra,  from  where  they  radiate  along  the  passage  to  the  glans,  and  also 
backwards  to  the  anus.  This  vesicular  colic  he  considered  to  be  due  to 
a  mechanical  obstruction  in  one  or  both  ejaculatory  ducts,  and  to  be 
absolutely  comparable  with  renal  colic. 

The  changes  in  the  generative  functions  are  of  great  importance.  Painful 
erections  and  painful  pollutions  are  sometimes  complained  of,  or  the  ejacu- 
lation is  premature.  "  The  diseased  seminal  vesicle  expels  the  semen  in 
the  same  way  as  an  inflamed  bladder  gets  rid  of  its  urine  "  (Guiard).  Others ' 
again,  become  impotent.  The  pathological  changes  in  the  seminal  vesicles 
and  in  their  excretory  ducts  may  bring  about  sterility. 

Occasionally  the  sperma   is   blood-stained.     This   condition,  which  is 

^  Reliquet,  Coliques  Spermatiques,  Paris,  1880. 


THE  COMPLICATIONS  OF  GONORRHEA  205 

called  "  hemospermia,"  is  only  characteristic  for  a  lesion  of  the  seminal 
vesicles  if  sperma  and  blood  are  thoroughly  mixed.  One  should  bear  this 
in  mind,  as  a  urethral  ulcer  may  cause  a  little  bleeding  when  ejaculation 
takes  place.  In  spermato-cystitic  hemospermia  the  semen  is  usually 
yellowish  and  "  rusty."  When  this  symptom  is  definite,  it  becomes  just 
as  important  as  the  rusty  sputum  in  pneumonia.  When  the  blood  is  very 
abundant,  and  has  been  for  some  time  in  the  vesicles,  the  colour  is  darker, 
and  may  be  as  black  as  ink. 

The  examination  of  the  urine,  which  should  always  be  passed  into  four 
glasses,  enables  one  often  to  make  a  provisional  diagnosis  of  vesiculitis. 
If  the  urethral  discharge  ceases  after  a  series  of  urethro-vesical  irrigations, 
and  if,  despite  the  very  small  amount  of  oozing  still  present,  the  urine 
continues  to  be  uniformly  turbid  in  the  four  glasses,  a  vesiculitis  is  prob- 
able, and  a  local  examination  is  indicated. 

Frequency  of  micturition  is  also  not  uncommon.  Some  patients  have 
to  make  water  every  fifteen  or  thirty  minutes.  Occasionally  there  is  also 
vesical  pain  when  the  bladder  is  full  or  during  the  act  of  micturition. 

Phosphaturia  is  generally  present,  but  it  is  not  due  to  a  disturbance  of 
the  functions  of  the  kidneys.  It  owes  its  presence  solely  to  the  condition 
of  the  seminal  vesicles,  as  is  easily  shown.  When  the  patient  makes  water 
into  four  glasses,  there  is  a  considerable  difference  between  the  urine  in  the 
first  glass  and  the  remainder.  The  first  glass  is  turbid,  whilst  the  others  are 
clear.  This  phosphaturia  is  thus  simply  due  to  the  fact  that  a  few  drops 
of  the  vesicular  secretion  find  their  way  into  the  posterior  urethra,  and  carry 
phosphates  with  them,  which  the  initial  flow  of  urine  washes  away  into  the 
first  glass. 

Acute  gonorrheal  vesiculitis  is  often  accompanied  by  marked  general 
symptoms.  High  fever  is  by  no  means  rare,  especially  if  a  digital  explora- 
tion has  been  carried  out  during  the  acute  or  hyperacute  stage.  One  then 
usually  notes  general  malaise,  pallor,  fatigue,  and  loss  of  appetite. 

The  diagnosis  can  only  be  made  by  examining  the  vesicles  yer  rectum, 
and  for  this  purpose  the  patient  should  be  placed  in  the  position  described 
on  p.  106.     The  horizontal  position  is  insufficient. 

The  finger  is  deeply  introduced  into  the  rectum.  One  seeks  and  palpates 
the  lobes  of  the  prostate,  and  then  feels  above  them  the  two  seminal  vesicles. 
In  health  they  are  insensitive,  and  almost  imperceptible  to  the  touch;  but 
when  they  are  inflamed,  the  digital  palpation  is  horribly  painful,  and  may 
cause  the  patient  to  faint.  The  vesicles  are  felt  as  elongated,  more  or  less 
large  masses,  which  run  upwards  and  outwards  above  the  horns  of  the 
prostate.  One  cannot  insist  too  strongly  upon  the  necessity  of  palpating 
very  gently,  especially  when  the  inflammation  is  acute,  on  account  of  the 
violent  attacks  of  fever  which  may  supervene. 


206  GONOKKHEA 

One  has  proposed  to  resort  to  puncture  of  the  vesicles  for  the  diagnosis 
of  spermato-cystitis.  This  exploration  can  be  carried  out  through  the 
rectum  or  through  the  perineum. 

Exploratory  puncture  per  rectum  is  easy.  One  passes  the  needle  into 
the  terminal  gut  after  having  introduced  a  speculum,  or  simply  under  the 
guidance  of  the  finger.  The  danger  of  perforating  the  bladder  is  not  as 
great  as  one  might  think,  providing  one  holds  the  needle  in  the  direction 
of  the  gut  wall,  and  not  at  a  right  angle  to  it.  A  fistula  between  the  punc- 
tured vesicle  and  the  rectum  is,  however,  apt  to  supervene,  and  therefore 
this  operation  cannot  be  recommended. 

The  perineal  route  is  preferable.  One  makes  an  incision  at  a  point 
which  is  3  centimetres  in  front  of  the  anus  and  3  centimetres  to  one  side 
of  the  median  raphe,  traverses  the  fat  of  the  ischio-rectal  fossa,  and  passes 
along  the  side  of  the  prostate.  By  putting  a  finger  into  the  rectum,  one 
can  guide  the  direction  of  the  needle  more  easily.  In  this  way  the  needle 
enters  the  seminal  vesicle  immediately.  This  method  is  practically  free 
from  risk,  and  it  allows  one,  if  one  has  withdrawn  pus  from  the  vesicle,  to 
utiUze  the  exploratory  needle  as  a  director,  and  to  perform  a  more  complete 
operation. 

The  prognosis  should  be  a  guarded  one.  In  many  cases  the  course  of 
a  spermato-cystitis  is  benign,  but  this  is  not  always  so. 

An  abscess  of  the  seminal  vesicle  may  perforate  and  discharge  its  con- 
tents into  one  of  the  neighbouring  body  cavities.  Unfortunately,  it 
bursts  not  infrequently  into  the  peritoneal  sac,  and  sets  up  a  fatal  perito- 
nitis.^   Kocher  has  published  several  cases  of  this  kind.^ 

Opening  into  the  rectum  is  less  common.  Vadja  has  published  an 
example. 

As  a  rule,  these  abscesses  burst  into  the  urethra  or  into  the  bladder. 
This  took  place  in  one  of  Wildbolz's  cases. 

The  relative  thinness  of  their  walls  and  the  richness  of  their  vascular 
supply  explain  readily  why  a  spermato-cystitis  is  so  dangerous.  In  men  who 
are  suffering  from  a  generalized  gonococcal  infection,  the  starting-point  may 
be  taken  to  be  in  the  seminal  vesicles.  In  this  respect  it  would  be  interesting 
to  examine  systematically  a  series  of  cases  of  gonorrheal  rheumatism,  for 
instance,  and  to  ascertain  if  an  inflammation  of  their  seminal  vesicles  was 
the  starting-point  of  the  general  infection.  I  am  convinced  that  this  is  so, 
as  in  practically  every  case  which  has  come  under  my  notice  or  my  care 
a,  gonorrheal  spermato-cystitis  preceded  the  systemic  complications  (rheu- 
matism, myelitis,  etc.).     One  should  therefore  always  consider  the  possi- 

1  Wildbolz,  Ann.  des  Mai.  des  Org.  Genito-Urin.,  1903,  p.  1521. 

2  Kocher,  "Die  Krankheiten  der  Mannl.  Geschlechtsorgane,"  Deutsch.  Chirurg., 
1887. 


THE  COMPLICATIONS  OF  GONORRHEA  207 

bility  of  a  general  infection  supervening  when  a  seminal  vesicle  is  the  seat 
of  a  gonorrheal  inflammation. 

Amongst  the  other  complications  observed  in  the  course  of  a  protracted 
gonorrheal  vesiculitis,  attacks  of  pain  along  the  ureters  should  be  mentioned. 
Picker  was  one  of  the  first  to  point  out  their  occurrence  in  the  course  of 
spermato- cystitis.  They  are  often  very  severe,  and  simulate  renal  colic, 
so  much  so  that  a  wrong  diagnosis  is  very  apt  to  be  made,  unless  one  is 
acquainted  with  the  history  of  the  case.  The  origin  of  these  pains  is  to 
be  found  in  the  compression  of  a  portion  of  the  ureter,  either  directly 
through  the  inflamed  vesicle,  or — and  this  is  more  often  the  case — through 
the  perivesiculitis  which  is  commonly  present  in  this  condition.  The 
lumen  of  the  ureter  may  become  partly  obliterated,  and  the  resulting 
obstruction  to  the  flow  of  urine  may  give  rise  to  the  pain  of  renal  tension 
which  is  observed  in  renal  colic. 

Spermato- cystitis  is  very  generally  accompanied  by  an  inflammation 
of  the  vas  deferens.  This  deferentitis  often  leads  to  an  irritation  of  the 
peritoneum. ■•■  Pain  in  the  lower  abdomen,  which  finally  becomes  general- 
ized all  over  the  peritoneal  cavity,  retching,  nausea,  vomiting,  increase  in 
the  pulse-rate,  and  rapid  respiration,  are  then  noted,  so  much  so  that 
the  diagnosis  of  appendicitis  is  easily  made.^  On  examination,  the  vas 
deferens  is  found  to  be  enlarged ;  it  often  resembles  a  thick  hard  cyhnder, 
which  projects  through  the  superficial  inguinal  ring. 

Lastly,  vesiculitis  and  epididymitis  frequently  go  together,  and  it  is 
well  to  inform  patients,  who  are  suffering  from  an  inflammation  of  their 
vesicles,  of  this  fact. 

^  The  gravity  of  an  acute  inflammation  of  the  deep  sexual  organs  is  mainly  depen- 
dent on  their  relation  to  the  peritoneum. 

The  upper  part  of  the  seminal  vesicles  is  in  relation  with  the  peritoneum,  and  the 
vas  deferens  runs  under  its  cover  during  a  considerable  part  of  its  course.  Hence 
j)eritoneal  irritation,  and  even  inflammation,  are  frequently  observed  when  these  struc- 
tures are  acutely  inflamed.  In  severe  acute  epididymitis,  for  instance,  the  vas  is  always 
implicated,  and  through  it  the  peritoneum.  For  this  reason  all  the  alarming  symptoms 
which  are  observed  in  that  illness  are  peritoneal,  and  not  testicular  (pain  most  marked 
in  the  inguinal  region  and  lower  abdomen,  muscular  defence,  rapid  pulse,  constipation, 
■etc.).  It  is,  thus,  not  the  privilege  of  the  fair  sex  to  suffer  from  pelvic  peritonitis.  The 
role  played  by  the  vas  and  the  seminal  vesicles  is  absolutely  comparable  to  that  of  the 
JFallopian  tubes.  The  male  is  only  in  so  far  better  off  as  his  genital  gland  is  situated 
at  a  considerable  distance  from  the  peritoi  eum.  In  cryptorchids  who  are  unfortunate 
■enough  to  develop  a  gonorrheal  epididymitis  in  their  intra-abdominal  testicle,  the 
analogy  with  the  female  is  absolutely  complete. 

As  a  rule,  this  pelvic  peritonitis  in  the  male  terminates  by  resolution,  but  cases  like 
.those  of  Kocher  and  Wildbolz  mentioned  above  bring  home  its  dangers  and  its  impor- 
.tance  (A.  F.). 

^  Le  Fiir,  "  Deferentite  et  Appendicite,"  Bull,  de  Soc.  de  T Internal,  January,  1911, 
No.  1,  p.  22. 


208  GONORRHEA 

In  all  cases  the  course  of  a  spermato- cystitis  is  a  protracted  one  ;  its 
minimum  duration  is  two  months,  and  it  often  lasts  longer. 

The  treatment  naturally  varies  whether  the  inflammation  is  acute  or 
chronic. 

In  acute  gonorrheal  spermato- cystitis  local  interventions  should  be 
avoided.  Not  only  are  they  certain  to  give  rise  to  atrocious  pain,  but 
they  are  also  apt  to  bring  about  a  systemic  infection.  Massage  of  acutely 
inflamed  vesicles  is  to  be  condemned.  The  best  treatment  appears  to  be 
rest  in  bed,  the  intake  of  large  quantities  of  fluid,  urethro- vesical  irriga- 
tions with  weak  permanganate,  and  hot  rectal  irrigations,  which  are 
especially  valuable. 

The  chronic  cases  are  treated  by  means  of  massage  of  the  seminal 
vesicle.  This  therapy  is  carried  out  after  the  bladder  has  been  filled  with 
fluid  from  an  irrigator.  If  done  efficiently,  it  frees  the  afiected  organ  from 
its  purulent  debris,  which  is  subsequently  washed  away  as  the  patient 
passes  the  permanganate  within  his  bladder. 

In  certain  instances  the  vesicles  are  situated  at  a  very  high  level,  and  are 
beyond  the  reach  of  the  finger.  Electric  massage,  carried  out  with  Eeleki's 
instrument,  or  a  similar  apparatus,  can  then  be  resorted  to  with  advantage.^ 
This  massage  treatment  should  be  continued  until  the  urine  has  become 
clear.  When  this  has  been  achieved,  dilatation  should  be  resorted  to, 
using  Frank's  irrigating  dilator  towards  the  finish  of  the  treatment.  Lastly, 
urethroscopic  examinations  should  be  made,  in  order  to  verify  the  con- 
dition of  the  verumontanum  and  of  the  ejaculatory  ducts. 

A  vesiculitis  can  only  be  considered  to  be  cured  when  no  indurations 
are  left,  when  all  pain  in  the  region  of  the  vesicles  has  disappeared,  and 
when  no  longer  any  purulent  debris  comes  away  on  massage. 

Operative  Treatment  of  Spermato-Cystitis. — Unfortunately,  there  are 
cases  in  which  the  above  measures  fail.  It  is  then  necessary  to  consider 
the  advisability  of  a  surgical  intervention.-  These  operations  have  so  far 
been  done  chiefly  by  American  surgeons,  who  have  proposed  the  following 

operations : 

1.  Vesiculotomy  (Fuller). 

2.  Vesiculectomy  (Brandsford  Lewis). 

3.  Vasotomy  (Belfield). 

The  method  last  mentioned  owes  its  existence  to  Belfield  of  Chicago^ 
who  studied  in  1905  the  effects  of  injections  into  the  seminal  vesicles  on. 
the  cadaver.     He  injected  coloured  fluids  or  an  emulsion  of  iodoform  and. 

^  Feleki  has  also  devised  a  special  apparatus  fcr  heating  the  seminal  vesic]es,  -which 
consists  of  two  portions  through  which  a  circulaticn  of  hot  water  is  maintained.  The 
results  of  this  treatment  have  not  yet  teen  published. 

2  Vide  p.  222  (A.  F.). 


THE  COMPLICATIONS  OF  GONORRHEA  209 

glycerine  into  the  vas  deferens,  and  studied  their  penetration.  He  found 
it  possible  to  fill  the  whole  genital  apparatus  in  this  way.  His  technique 
consists  in  exposing  the  vas  through  a  small  incision  under  local  anesthesia, 
separating  it,  and  making  a  small  incision  into  it.  Through  this  opening 
the  cannula  of  a  syringe  containing  protargol,  argyrol,  or  5  per  cent.collargol, 
is  introduced,  and  the  drug  is  injected  into  the  seminal  vesicles. 

Belfield  uses  these  collargol  injections,  not  only  for  therapeutic  purposes, 
but  also  for  rendering  the  seminal  vesicles  visible  under  the  X  rays.^ 

Vesiculotomy  has  been  chiefly  advocated  by  Fuller,  whose  technique 
is  the  following  :  The  patient,  whose  rectum  has  been  cleansed  by  purges 
and  enemata,  is  placed  in  the  genu-pectoral  position.  A  curved  incision, 
the  convexity  of  which  is  directed  forwards,  is  traced  in  front  of  the  rectum. 
One  then  makes  one's  way  through  the  ischio-rectal  fossa,  and  separates  the 
prostate  and  the  seminal  vesicles  from  the  rectum,  the  left  index  being 
placed  in  the  latter  in  order  to  protect  it  against  being  injured.  In  this 
way  the  operation  is  not  very  difficult,  and  the  seminal  vesicles  are  reached 
without  any  trouble.  One  now  brings  a  grooved  director  into  them,  and 
incises  them  with  a  knife  which  has  been  introduced  along  the  groove  of 
the  director.  The  cutting  should  be  made  with  the  stout  part  of  the  blade, 
and  not  with  the  point.  After  the  pus  has  been  evacuated,  one  frees  the 
opened  vesicles  from  any  granulations  present  with  the  finger. 

According  to  Fuller,  this  operation  is  almost  bloodless,  and  hardly 
requires  any  ligatures.  It  is  a  somewhat  blind  procedure,  and  not  very 
scientific ;  but  it  appears  to  be  practically  sound  in  the  same  way  as  supra- 
pubic prostatectomy. 

Vesiculectomy  can  be  done  by  three  routes :  through  an  inguinal  incision, 
through  the  perineum,  and  through  the  ischio-rectal  route. 

A.  The  Inguinal  Route. — The  vas  deferens  serves  as  guide,  and  in  this 
way  the  operation  becomes  a  retroperitoneal  one.  An  incision  is  made 
from  the  antero-superior  spine  of  the  ilium  to  the  scrotum,  and  the  inguinal 
canal  is  opened  in  its  whole  length.  The  vas  is  drawn  forwards,  whilst 
the  peritoneum  is  pushed  back.  By  following  the  vas  downwards,  one 
gradually  reaches  the  vesicles,  which  one  isolates  with  the  fingers  and 
removes. 

B.  The  Perineal  Route. — An  incision  similar  to  the  crescent-shaped 
one  for  perineal  prostatectomy  is  made.  One  passes  between  the  muscles 
which  attach  the  rectum  to  the  membranous  urethra,  and  thus  reaches 
the  separable  zone  along  which  one  frees  the  rectum  from  the  prostate  and 
bladder.  Unless  the  latter  organ  be  distended,  the  seminal  vesicles  lie  at 
a  considerable  depth,  and  are  very  difficult  to  reach.  In  any  case,  the 
perineal  route  does  not  appear  to  be  very  recommendable. 

^  William  Belfield  of  Chicago,  Urological  Society,  October  25,  1906. 

14 


210  GONORRHEA 

C.  The  Ischio-Rectal  Route. — According  to  Voelcker,  this  method  is 
the  most  satisfactory  one  for  removing  the  seminal  vesicles.  In  his  in- 
teresting book^  he  advises  the  following  technique:  The  patient  lies  on  his 
abdomen,  with  his  head  hanging  down  and  his  coccyx  considerably  raised, 
whilst  the  legs  are  allowed  to  drop  down.  In  order  to  prevent  an  infection 
of  the  wound,  the  rectum  is  closed  by  a  temporary  ligature  of  its  mucous 
membrane  after  it  has  been  emptied.  An  incision  which  is  parallel  with 
the  middle  line,  is  made  along  the  side  of  the  anus  as  far  as  the  last  piece 
of  the  sacrum.  The  lower  fibres  of  the  gluteus  maximus  are  then  separated, 
and  the  ischio-rectal  fossa  comes  into  view.  In  the  deep  part  of  the  wound 
the  fibres  of  the  levator  ani  become  visible.  They  are  separated  and  in- 
cised. The  bare  rectum  then  comes  into  view,  and  is  pushed  aside.  The 
prostate  and  the  seminal  vesicles  are  then  free  within  the  cavity  exposed, 
and  can  be  excised  or  extirpated. 

The  Catheterization  of  the  Ejaculatory  Ducts. 

Considering  the  wonderful  ease  with  which,  thanks  to  the  perfection 
of  our  modern  instruments,  the  ureters  can  be  catheterized,  it  would  appear 
somewhat  strange  that  a  similar  intervention  should  not  have  been  attempted 
on  the  ejaculatory  ducts.  However,  the  literature  is  practically  silent  on 
this  question. 

Klotz^  thought  of  this  operation  in  1905,  and  invented  a  small  syringe, 
which  was  fitted  with  a  fine  cannula.  He  intended  to  introduce  the  latter 
into  the  ejaculatory  ducts,  and  to  inject  solutions  into  the  seminal  vesicles 
in  this  way.  His  procedure  was,  however,  unsuccessful,  as  his  injection 
gave  rise  to  epididymitis. 

Klotz's  attempt  is  certainly  interesting,  and  the  moment  seems  near 
when  one  will  be  able  to  wash  and  cleanse  the  seminal  vesicles  in  the  same 
way  as  one  irrigates  the  renal  pelvis  in  pyelonephritis. 

Already  now  one  may  say  that  this  catheterization  is  possible,  and  that 
it  has  its  definite  indications. 

Luys  was  the  first  to  catheterize  an  ejaculatory  duct  successfully,  and 
this  intervention  proved  most  beneficial  to  the  patient.^ 

A  man  of  forty  was  brought  to  him  in  August,  1912,  by  Mr.  HabiboUah,  assistant 
in  the  Paris  hospitals.  He  had  had  three  attacks  of  gonorrhea,  which  had  given  rise 
to  complications  (orchites  and  prostatitis). 

He  had  a  profuse  discharge  Tvhen  Luys  saw  him,  which  contained  gonococci.  All 
four  glasses  were  uniformly  turbid.     The  examination  showed  the  prostate  to  be 

^  Voelcker,  Chirurgie  der  Samenblasen,  Heidelberg,  1912. 
2  Klotz,  New  York  Medical  Journal,  January  26,  1905. 
2  Luys,  La  Clinique,  No.  7,  February  14,  1913. 


THE  COMPLICATIONS  OF  GONORRHEA  211 

definitely  inflamed.  There  were  hard  indurated  nodules  in  the  epididymes,  and  the 
seminal  vesicles,  especially  the  left  one,  were  painful. 

The  treatment  consisted,  to  begin  with,  in  irrigations  with  permanganate  and 
massage  of  the  prostate  and  the  seminal  vesicles.  The  urethra  was  then  dilated  with 
curved  metal  sounds  up  to  No.  58  G,  and  subsequently  with  Frank's  instrument. 

In  the  first  days  of  January,  1913,  the  left  seminal  vesicle  was  still  tender,  despite 
this  treatment,  and  it  was  noteworthy  that  the  massage  of  this  organ  gave  rise  to  intense 
pain,  and  failed  to  evacuate  the  contents.  Moreover,  this  treatment  was  followed  by 
a  fresh  attack  of  epididymitis  on  the  left  side,  although  no  instrument  was  used  inside 
the  urethra.  The  inflammation  of  the  left  testis  was  mild,  and  yielded  rapidly  to  rest 
in  bed  for  three  or  four  days.  The  whole  course  of  events  proved  clearly  that  massage 
was  unable  to  empty  the  diseased  vesicle,  and  that  its  ejaculatory  duct  was  obstructed. 
This  led  Luys  to  attempt  to  re-establish  its  permeability. 

After  all  the  inflammation  inside  the  urethra  had  disappeared,  Luys  urethroscoped 
the  patient  with  a  tube  No.  26  (January  17,  1913).  It  was  easy  to  see  the  verumon- 
tanum,  which,  thanks  to  the  previous  treatment,  was  free  from  inflammation,  and  did 
not  bleed. 

On  its  lateral  aspects  the  orifices  of  the  ejaculatory  ducts  were  visible.  Attempts 
were  made  to  catheterize  the  orifice  on  the  left  side  of  the  verumontanum  with  a 
urethral  sound  No.  5,  but  every  time  the  instrument  reached  the  opening  it  slipped 
off  the  curved  and  shiny  surface  of  the  verumontanum,  and  failed  to  enter  the  orifice. 
Luys  therefore  took  a  small  blunt  probe,  which  passed  into  the  opening  of  the  ejacula- 
tory duct  with  the  greatest  ease.  As  its  end  was  conical,  there  was  a  slight  resistance, 
and  then  the  probe  entered  the  ejaculatory  duct  for  a  distance  of  1-5  centimetres. 

Immediately  after  the  catheterization  the  bladder  was  filled  with  a  solution  of  oxy- 
cyanide  of  mercury,  and  the  vesicle  was  massaged.  To  his  great  surprise,  Luys  found 
that  the  massage  was  no  longer  so  painful,  and  that  enormous  masses  of  purulent  debris 
dropped  into  the  glass  held  in  front  of  the  meatus.  Never  before  had  massage  been  so 
successful,  and  yielded  so  much  material,  in  this  patient. 

No  ill  effects  followed.  The  induration  in  the  left  epididymis  diminished,  the  urine 
became  perfectly  clear,  and  ceased  to  contain  any  filaments.  Ten  days  later  the 
patient  was  seen  again,  and  was  found  again  to  be  free  from  any  signs  or  symptoms. 

It  thus  seems  that  the  catheterization  of  the  ejaculatory  ducts  can  and 
should  be  recommended,  when  these  channels  are  stenosed  and  prevent  the 
emptying  of  the  seminal  vesicles. 


Indications  for  the  Catheterization  of  the  Ejaculatory  Ducts. 

1.  The  first  indication  seems  to  be  the  one  which  served  as  guide  in  the 
case  just  described — i.e.,  Vesicular  Retention.  When  proper  massage  fails 
to  evacuate  a  seminal  vesicle,  the  corresponding  ejaculatory  duct  is  obviously 
obstructed,  and  it  is  legitimate  to  try  to  establish  its  permeability  in  the 
same  way  as  one  dilates  a  urethral  stricture  when  there  is  retention  of  urine. 

2.  In  Painful  Ejaculations. — When  a  patient  feels  a  sharp  pain  during 
coitus,  the  question  of  atresia  of  one  or  of  both  ejaculatory  ducts  has  to 
be  considered. 

3.  In  Blood-stained 'Ejaculations. — Blood-stained  ejaculations  maybe 
due  to  a  chronic  affection  of  the  seminal  vesicles  or  to  a  change  in  the 


212  GONORRHEA 

ejaculatory  ducts.     In  both  instances  the  catheterization  of  the  ejaculatorj 
ducts  appears  to  be  indicated. 

4.  In  Chronic  Spermato-Cystitis. — As  everybody  knows,  inflammation 
of  the  seminal  vesicles  is  very  common  in  gonorrhea.  It  is  one  of  its 
longest,  most  serious,  and  most  rebellious  complications.  Despite  its 
frequency,  it  is  comparatively  seldom  diagnosed,  owing  to  the  vagueness 
of  its  functional  symptoms,  and  passes  unnoticed  for  a  long  time.  For 
this  reason  it  should  always  be  sought  for  systematically.  One  should 
bear  in  mind  the  importance  of  a  urethroscopic  examination  of  the  veru- 
montanum,  and  its  intimate  pathological  relation  to  the  seminal  vesicles. 
The  urethroscopic  picture  of  the  verumontanum  often  allows  one  to  diagnose 
a  vesiculitis.     In  the  same  way  as  the  cystoscopic  aspect  of  the  ureteric 


Fig.  127. — Normal  Verumontanum  with  a  Visible  Single  Median  Utbiculus. 

orifices  permits  one  in  many  instances  to  conclude  that  a  pyonephrosis  'is 
present,  the  prostatic  utriculus  may  be  termed  the  "  mirror  of  the  seminal 
vesicles." 

The  catheterization  of  the  ejaculatory  ducts  in  chronic  spermato- 
cystitis  allows  one  to  obtain  a  good  evacuation  of  the  pathological  secretions 
contained  in  the  affected  vesicle,  or  to  inject  antiseptic  fluids  into  it. 

Technique. — One  selects  a  tube  14  centimetres  long,  of  a  suitable 
diameter,  cleans  the  urethral  mucous  membrane  by  means  of  an  irrigation, 
and  passes  the  tube  according  to  the  rules  as  far  as  the  prostatic  fossette. 
One  then  reaches  the  anterior  aspect  of  the  verumontanum,  which  may  show 
a  single  median  utriculus  (Fig.  127).  In  other  cases  there  is  no  utriculus 
in  the  middle  line.  On  the  lateral  aspects  of  the  verumontanum  two 
symmetrical  openings,  which  are  the  orifices  of  the  ejaculatory  ducts,  are 
visible  to  either  side  of  the  crest.  The  verumontanum  has  then  the  shape 
of  a  diver's  helmet  (Fig.  128). 


THE  COMPLICATIONS  OF  GONORRHEA  213 

In  cases  of  this  type  the  catheterization  is  much  easier.  It  is  best  to 
use  a  straight  metal  probe,  which  is  passed  along  the  tube,  the  lamp  of 
which  must  be  lying  on  the  upper  wall.  In  this  way  one  reaches  the 
orifice  of  the  ejaculatory  duct,  and  the  blunt  end  of  the  probe  can  enter  in 
the  same  way  as  a  ureteric  catheter.  By  means  of  a  few  gentle  vertical 
a]id  horizontal  movements  one  can  widen  the  opening  a  bit,  and  then  one 
passes  the  instrument  1  to  2  centimetres  into  the  lumen.  One  stops  when 
one  feels  a  slight  resistance.  As  a  rule,  this  intervention  is  perfectly  pain- 
less ;  there  is  no  bleeding,  or  it  is  trifling. 

When  a  single  median  utriculus  is  present,  one  proceeds  in  a  similar 
manner.     One  directs  the  probe  into  the  utriculus,  and  then  one  brings 


Fig.  128. — Verumontantjm  without  a  Median  Utbicul-us. 

The  two  ejaculatory  ducts  open  on  its  lateral  aspects,  giving  it  the  appearance 
of  a  diver's  lielmet. 

the  handle  to  one  side  (to  the  left  for  the  left  duct,  and  to  the  right  for  the 
right  one).  After  a  few  very  gentle  essays,  the  probe  enters  the  ejaculatory 
duct. 

This  intervention  should  be  reserved  for  special  cases.  It  is  absolutely 
contra-indicated  when  the  posterior  urethra  is  in  a  state  of  acute  inflamma- 
tion. One  has  always  to  wait  until  all  acute  changes  have  subsided.  As  a 
rule,  it  is  also  necessary  to  urethroscope  the  patient  on  several  occasions 
previously,  and  to  prepare  the  verumontanum.  Caustics  should  be  applied 
to  render  its  surface  smooth,  and  to  prevent  it  from  bleeding.  Only  then 
will  the  orifices  of  the  ejaculatory  ducts  be  clearly  visible.  It  would  appear 
as  if  the  catheterization  of  the  ejaculatory  ducts  would  never  give  rise  to 
any  trouble  under  these  conditions.  On  the  contrary,  it  seems  to  be  one 
of  the  most  beautiful  achievements  of  modern  urethroscopy. 


214  GONORRHEA 

Gonorrheal  Cystitis. 

Gonorrheal  cystitis  usually  supervenes  upon  an  inflammation  of  the 
posterior  urethra.  It  comes  on  most  frequently  about  the  third  or  fourth 
week  of  the  infection,  and  is  nearly  always  the  result  of  a  direct  contamina- 
tion, the  gonococci  being  carried  into  the  bladder  by  means  of  an  instrument 
or  of  forcible  injections,  or  through  some  untimely  local  intervention  on 
the  urinary  passages. 

In  a  few  cases  violent  exercise,  venereal  excess,  riding  on  horseback 
or  in  a  carriage  whilst  the  gonorrhea  is  still  in  the  acute  stage,  may  lead  to 
implication  of  the  bladder. 

The  organism  usually  at  fault  is  the  gonococcus.  In  certain  cases, 
however,  only  the  bacteria  of  a  secondary  infection  are  found. 

It  has  seldom  been  possible  to  study  the  morbid  anatomy  of  gonorrheal 
cystitis.  But  cystoscopic  examinations  undertaken  in  cases  of  gonorrheal 
cystitis  have  given  us  sufficient  information  to  enable  us  to  form  an  idea 
of  the  lesions  present.  In  most  cases  the  vesical  mucous  membrane  is  in 
a  state  of  generalized  diffuse  inflammation,  which  is  sometimes  accom- 
panied by  a  more  or  less  marked  edema.  In  places  raised  folUcles,  repre- 
sented by  accuminated  dark  red  spots,  are  visible  on  the  mucosa.  The 
lesions  are  usually  most  pronounced  near  the  internal  sphincter,  at  the  level 
of  the  trigone.  Histological  researches  have  shown  that  the  vesical 
epithelium  soon  undergoes  desquamation  in  gonorrheal  inflammation,  and 
that  it  is  replaced  by  a  proliferation  of  the  subepithelial  tissue.  The 
vessels  of  the  latter  are  widely  dilated,  and  filled  with  leucocytes,  most  of 
which  are  laden  with  gonococci  (Finger). 

Cystitis  is  characterized  by  the  following  symptoms : 

1.  Frequency  of  micturition  accompanied  by  vesical  tenesmus.  The 
desire  to  micturate  becomes  frequent,  imperative,  and  repeats  itself  every 
forty-five  minutes,  or  even  more  often — say  every  five  minutes.  It  is  less 
accentuated  when  lying  down  than  on  walking  or  standing.  Once  micturi- 
tion is  terminated,  the  desire  to  repeat  the  act  starts  afresh,  although  the 
bladder  is  empty.     This  condition  is  called  "  tenesmus." 

2.  The  pain  is  most  marked  at  the  end  of  micturition.  The  expulsion 
of  the  last  drops  is  the  starting-point  of  an  intense  pain. 

3.  The  urine  is  practically  always  purulent,  and,  when  the  patient 
makes  water  into  several  glasses,  the  last  specimen  is  the  most  turbid. 
There  is  usually  some  blood  in  the  urine,  especially  towards  the  end. 
Occasionally  the  last  drops  of  fluid  passed  are  pure  blood. 

The  course  of  the  disease  is  variable.  If  left  to  itself,  resolution  may  take 
place  in  a  few  days.  But  a  recrudescence  is  very  common,  and  this  is  a 
characteristic  feature  of  the  malady. 


THE  COMPLICATIONS  OF  GONORRHEA  215 

An  acute  cystitis  lasts  usually  eight  to  ten  days.  In  certain  cases  it 
becomes  chronic,  and  then  it  lasts  much  longer.  If  it  takes  a  chronic 
course,  it  should  be  attended  to  with  great  care,  because  a  tuberculous 
cystitis  is  likely  to  develop  ultimately. 

The  diagnosis  is  usually  easy,  and  is  made  by  the  aid  of  the  three  symp- 
toms just  described.  Sometimes,  however,  the  difl6.culty  of  distinguishing 
between  a  gonorrheal  and  a  tuberculous  cystitis  is  very  great,  especially 
if  the  latter  grafts  itself  on  the  former. 

In  such  doubtful  cases  the  urine  should  be  centrifuged,  and  the  deposit 
sliould  be  inoculated  into  guinea-pigs  in  order  to  clinch  the  diagnosis. 

The  medical  treatment  is  very  important.  In  the  first  place,  the  patient 
should  be  confined  to  his  bed  and  take  plenty  of  fluid.  Infusions  of  cherry 
stalks,  or,  better,  of  folia  uvae  ursi  are  recommendable. 

One  of  the  best  prescriptions  is  the  following:  The  patient  takes  three 
times  per  day  an  infusion  of  foha  uvse  ursi,  which  is  prepared  in  the  same 
way  as  tea,  and  sweetened  by  means  of  the  following  syrup : 

Syrup  of  tolu  . .  . .  . .  . .     300  grammes. 

Benzoate  of  sodium       . .  . .  . .  . .       15         ,, 

One  teaspoon  per  cup  of  infusion. 

Baths  and  sitz- baths  are  to  be  recommended.  The  amount  of  food 
taken  should  be  reduced,  and  replaced  by  a  milk  diet,  if  possible.  Hot 
applications  to  the  lower  abdomen  relieve  the  pain.  The  balsam  prepara- 
tions taken  internally  often  render  good  service.  Sandalwood- oil  especially 
works  wonders  in  certain  cases.  If  one  has  to  deal  with  a  hemorrhagic 
gonorrheal  cystitis,  accompanied  by  great  suffering,  it  is  best  to  confine 
the  patient  to  his  bed  and  to  let  him  take  ten  to  twelve  sandalwood-oil 
capsules  per  day.  The  blood  disappears,  and  the  pain  ceases  in  twenty-four 
hours. 

Apart  from  the  balsam  preparations,  urotropin  or  helmitol,  in  doses 
of  1*5  to  2  grammes  per  day,  should  be  given,  or  one  may  prescribe  turpen- 
tine. If  the  cystitis  is  accompanied  by  phosphaturia,  uraseptine  is  prefer- 
able to  urotropin,  because  it  acidifies  the  urine,  and  thus  allows  its  urotropin 
radical,  which  requires  an  acid  medium,  to  act  efficiently. 

Local  treatment  should  be  deferred  until  all  acute  inflammatory  phe- 
nomena have  subsided,  and  until  there  is  no  longer  any  blood  in  the  urine. 
The  treatment  which  would  be  the  most  appropriate,  varies  with  the  indi- 
vidual cases.  If  there  is  an  abundant  discharge  containing  gonococci, 
urethro-vesical  irrigations  with  weak  permanganate  are  preferable,  and 
they  should  be  combined  with  massage  of  the  prostate,  because  this  organ 
is  usually  implicated  when  cystitis  is  present.  In  many  instances  the 
prostatitis  is  the  direct  cause  of  the  cystitis. 


216  GONORRHEA 

When,  on  the  other  hand,  all  urethral  discharge  has  subsided,  the 
treatment  of  choice  consists  in  instillations  of  1  or  2  per  cent,  silver  nitrate 
every  other  day. 

If  the  nitrate  is  not  well  borne,  and  causes  excessive  pain,  it  can  be 
replaced  with  advantage  by  an  organic  silver  salt  (protargol,  argyrol,  etc.). 

Pyelitis  and  Pyelonephritis  of  Gonorrheal  Origin. 

It  is  by  no  means  rare  to  find  the  gonorrheal  infection  spreading  to  the 
kidney.^  Several  observations  have  been  recorded  by  Borkhardt  (1886), 
Mendelsohn,  Ashara  (1898),  Brandsford  Lewis,^  and  Hagner,  in  which  the 
gononcoccus  was  found  in  a  state  of  purity  in  the  pelvis  of  the  kidney  or 
in  abscesses  within  the  renal  tissue.  In  most  cases,  however,  the  infection 
is  a  mixed  one,  containing  chiefly  staphylococci,  streptococci,  and  coli 
bacilli.  In  these  cases  the  gonococcus  confines  itself  to  provoking  an  in- 
flammation, and  to  preparing  thus  the  soil  for  a  secondary  infection. 

Hagner^  has  reported  on  twenty-seven  personal  cases,  of  which  sixteen 
showed  a  mixed  infection,  whilst  nine  were  purely  gonococcal. 

Sellei^  observed  five  cases  in  which  the  gonococcus  was  associated  with 
Bacillus  coli. 

The  channels  through  which  the  gonococcus  reaches  the  kidney  are  the 
same  as  those  by  which  other  infectious  organisms  reach  that  organ — 
namely : 

1.  Through  the  Ureter. — Murchison  has  described  cases  in  which  a 
gonorrheal  cystitis  was  followed  by  an  inflammation  of  the  whole  ureter. 
In  most  cases  the  ascending  infection  supsrvenes  upon  retention,  whether 
the  latter  be  caused  by' a  stricture  of  the  urethra  or  by  an  inflammation  of 
the  prostate.  The  ureteric  orifices  are  enlarged,  and  gape  in  these  cases. 
The  urine  can  thus  flow  backwards  from  the  infected  bladder,  and  the 
gonococci  are  able  to  find  their  way  to  the  kidney. 

2.. Through  the  Blood-Stream. — The  gonococci  which  circulate  in  the 
blood-stream  are  carried  to  the  kidneys,  and  may  settle  there  in  the  same 
way  as  they  attack  the  articulations  and  the  cardiac  valves.  This  route 
is  the  only  feasible  one  when  there  is  no  concomitant  gonorrheal  cystitis. 

3.  Through  the  Lymphatics. — The  gonococci  set  free  from  a  prostatic 
abscess  can  travel  along  the  ureter  into  the  perirenal  tissue,  and  invade 
subsequently  the  kidney  itself. 

The  abuse  of  balsam  preparations  is  a  predisposing  factor  for  the  infec- 

^  Vide  on  this  question  Wossidlo,  loc.  cit,  p.  304. 

^  Brandsford  Lewis,  Journal  of  Cutaneous  and  Genito- Urinary  Diseases,  September, 
1900,  p.  167. 

2  Hagner,  "  Gonococcus  Infection  of  the  Kidney,"  Medical  Record,  1910,  p.  568. 
4  Sellei  and  Unterberg,  Berl.  Klin.  Woch.,  1907,  pp.  1113-1115. 


THE  COMPLICATIONS  OF  GONORRHEA  217 

tion  of  the  kidney  by  the  gonococcus.  Taken  in  large  doses,  they  irritate 
the  renal  epithelium,  and  thus  prepare  the  organ  for  an  invasion  by  Neisser's 
organism. 

Gonorrheal  pyelonephritis  is  usually  ushered  in  by  a  chill,  and  by 
fever  up  to  39°  or  40°  C. ;  but  its  onset  may  be  insidious,  and  be  indicated 
by  a  little  shivering  only.  As  soon  as  pyelonephritic  abscesses  are  formed, 
the  pulse  becomes  small  and  rapid,  and  violent  febrile  attacks  of  a  hectic 
character  set  in.  If  pus  is  present,  and  if  the  lumen  of  the  ureter  is  sufiB.- 
ciently  obliterated  to  bring  about  the  retention  of  the  pus  in  the  renal 
pelvis,  very  high  fever  is  common. 

Very  rapidly  one  of  the  kidneys  becomes  painful.  This  pain  may  be 
either  spontaneous  or  only  noticed  on  pressure.  It  may  be  unilateral  or 
bilateral.  It  may  radiate  along  the  ureter  into  the  bladder,  and  even  into 
the  penis,  or  it  may  be  referred  to  the  loins. 

Gastric  troubles  and  violent  headaches  usually  accompany  this  con- 
dition. The  tongue  is  coated,  the  appetite  is  lost,  and  diarrhea  and  consti- 
pation alternate. 

The  urine  is  found  on  examination  to  be  uniformly  turbid  at  the  time 
when  it  is  passed.  However,  if  only  one  kidney  is  affected,  and  if  its  ureter 
becomes  partly  occluded,  clear  and  turbid  specimens  may  be  obtained  in 
alternation.     The  urine  has  to  be  tested  repeatedly,  therefore,  in  these  cases. 

If  the  pyelitis  is  bilateral,  anuric  crises  may  supervene. 

The  deposit  obtained  by  centrifuging  the  urine  is  composed  of  pus, 
blood,  various  bacteria,  casts,  and  renal  cells.  Chemical  analysis  reveals 
the  presence  of  albuminuria.  Palpation  of  the  kidneys  does  not  give  any 
information  as  a  rule,  but  it  may  show  the  pain  to  be  limited  to  one  kidney, 
or,  if  carried  out  bimanually,  it  may  prove  one  of  the  organs  to  be  enlarged. 

The  diagnosis  is  usually  very  difficult,  and  in  many  instances  it  has 
only  been  made  post  mortem.  The  appearance  of  shivering,  fever,  and  pain 
in  the  loins,  during  an  attack  of  gonorrhea,  should  make  one  suspect  a  pyelo- 
nephritis. The  histological  and  chemical  examination  of  the  urine  is  the 
chief  guide  to  diagnosis;  the  presence  of  casts  and  of  a  considerable  quantity 
of  albumin  often  decide  the  nature  of  the  case.  Cystoscopy  and  catheter- 
ization of  the  ureter  allow  one  to  complete  the  diagnosis. 

The  treatment  of  gonorrheal  pyelonephritis  is  similar  to  that  of  other 
types  of  pyelonephritis.  Rest  in  bed,  very  low  diet  (water,  milk),  and 
purgation  are  indicated.  No  alcohol  should  be  allowed;  16  grammes  of 
urotropin  internally  per  day  should  be  given. 

Kelly  and  Casper  recommend  irrigations  of  the  renal  pelvis  with  boric 
lotion,  or  with  a  0-1  per  cent,  solution  of  silver  nitrate  through  a  ureteric 
catheter.    Argyrol  may  also  be  used. 

More  serious  cases  require  a  nephrotomy,  or  even  a  nephrectomy. 


218  GONOKRHEA 


Retention  of  Urine. 


Retention  of  urine  occurs  during  gonorrhea  under  difEerent  conditions. 

In  the  acute  stage  the  urethral  mucous  membrane  may  be  so  swollen 
and  edematous  that  the  urine  finds  its  normal  channel  closed.  This 
accident  is  often  met  with  in  little  boys. 

When  the  prostate  and  the  seminal  vesicles  are  the  seat  of  acute  gonor- 
rheal inflammation,  retention  is  also  common,  and,  like  these  troubles,  it 
is  usually  the  result  of  bad  or  untimely  local  treatment. 

In  other  instances  it  follows  upon  an  acute  inflammation  of  Cowper's 
glands,  or  it  may  result  from  an  old  stricture,  which  suddenly  swells  up 
under  the  influence  of  a  fresh  gonococcal  infection. 

Lastly,  the  nervous  complications  of  gonorrhea  may  be  accompanied 
by  retention,  as  in  the  case  of  gonorrheal  myelitis  described  on  p.  248. 

The  treatment  should  be  at  first  medical.  The  intake  of  plenty  of  fluid, 
prolonged  hot  baths,  and  hot  enemata  are  of  service. 

The  more  important  local  treatment  should  be  preceded  by  a  rectal 
exploration  of  the  prostate  and  of  the  seminal  vesicles,  in  order  to  ascertain 
if  an  inflammation  of  these  organs  is  at  the  bottom  of  the  mischief.  Should 
this  be  the  case,  the  patient  is  placed  in  the  genu-pectoral  position,  and 
energetic  rectal  massage  is  carried  out.  In  certain  cases  a  prostatic  abscess 
can  be  opened  in  this  way,  and  its  evacuation  may  be  followed  by  spon- 
taneous micturition.  Treatment  of  this  kind  should,  however,  be  avoided 
(or,  at  any  rate,  one  should  be  very  cautious)  if  the  seminal  vesicles  are  in 
a  state  of  acute  inflammation,  for  serious  generalized  complications  might 
follow  otherwise. 

Lastly,  when  the  palliative  measures  have  failed,  one  has  to  make  up 
one's  mind  to  pass  a  catheter.  A  soft  rubber  catheter,  No.  15  or  16,  is 
best  for  this  purpose.  Its  introduction  should  always  be  preceded  by  a 
thorough  cleansing  of  the  anterior  urethra  with  boric  lotion.  The  passing 
of  the  catheter  gives  the  patient  immediate  relief,  and  may  be  repeated, 
as  long  as  the  bladder  requires  it,  until  normal  micturition  is  re-established. 
Under  no  circumstances  whatsoever  is  it  permissible  to  leave  the  catheter 
in  the  urethra  and  to  tie  it  in. 


GENERAL  SYSTEMIC  COMPLICATIONS  OF  GONORRHEA. 

Gonorrheal  Rheumatism. 

Gonorrheal  rheumatism  is  a  distinct  morbid  entity,  which  is  quite 
different  from  ordinary  rheumatism.  Its  clinical  manifestations  are  fre- 
quently so  typical  that  they  alone  would  be  suflScient  to  recognize  it  as  a 
definite  autonomous  disease. 


THE  COMPLICATIONS  OF  GONORRHEA  219 

The  pathology  of  gonorrheal  rheumatism  has  been  under  discussion 
for  a  considerable  time.  Some,  like  Hervieux,  saw  in  the  association  of 
gonorrhea  and  rheumatism  nothing  but  a  mere  coincidence;  but  Fournier 
and  Fereol  soon  realized  that  the  rheumatism  originating  during  an  attack 
of  gonorrhea  was  related  to  the  infection  of  the  urethra,  and  caused  by  it. 

Peter  believed  gonorrhea  to  be  merely  a  favourable  occasion,  like  cold, 
moisture,  and  fatigue,  for  the  outbreak  of  rheumatism  in  "rheumatic 
subjects."  Fournier,  on  the  contrary,  held  that  gonorrhea  was  not  only 
a  predisposing  cause,  but  the  efficient  and  necessary  cause. 

Sex  and  age  have  very  little  bearing  upon  the  incidence  of  gonorrheal 
rheumatism.  It  would  seem,  however,  as  if  men  were  more  often  affected 
than  women.  Other  occasional  causes  which  have  often  been  pointed  out, 
are  cold,  violent  exercise  (riding,  excessive  walking,  etc.),  and  a  peculiar 
predisposition. 

As  to  the  relative  frequency  of  gonorrheal  rheumatism,  about  2  per  cent. 
of  all  cases  of  gonorrhea  develop  this  complication. 

At  the  present  stage  of  our  knowledge,  the  pathogeny  of  gonorrheal 
rheumatism  can  be  resumed  in  one  sentence:  Migration  of  the  gonococcus 
to  the  joints,  where  it  settles  down  and  multiplies.  Even  when  the  joints- 
yield  on  aspiration  a  fluid  which  contains  no  gonococci,  their  absence  cannot 
be  considered  to  be  proved,  as  there  is  every  chance  that  they  may  be 
found  on  another  occasion. 

A  great  number  of  microscopic  examinations  have  established  beyond 
doubt  that  gonorrheal  rheumatism  is  definitely  the  result  of  the  specific 
action  of  the  gonococcus. 

The  organism  can  be  found  in  the  pus  contained  in  the  joints,  but  it 
is  necessary  to  examine  the  articular  fluid  in  the  course  of  the  first  days 
which  follow  upon  the  involvement  of  the  joint,  if  one  wishes  to  find  the 
gonococcus.  It  disappears  soon,  and  examinations  carried  out  at  a  later 
date  yield  a  negative  result.  In  cases  in  which  the  pus  is  sterile,  the 
exudate  which  is  obtainable  after  opening  and  scraping  the  synovial  mem- 
brane often  contains  the  coccus.  Lastly,  cultures  may  be  made  to  confirm 
the  presence  of  the  gonococcus. 

Gonorrheal  rheumatism  may  complicate  any  gonorrheal  infection, 
whether  it  be  a  urethritis,  or  a  gonorrheal  ophthalmia,  or  other  manifesta- 
tion. Weiss  and  Klingelhoeff  er^  observed  a  male  nurse,  aged  thirty-five,  who 
received  some  pus  from  a  urethritis  into  his  eye,  and  severe,  intense,  purulent 
conjunctivitis  supervened  within  two  days,  which  was  treated  by  means 
of  installations  of  silver  nitrate  and  permanganate  irrigations.  After  five 
weeks  the  eye  was  almost  well,  when  the  patient  suddenly  complained  of 
sharp  pains  in  his  right  knee,  the  skin  of  which  was  reddened.     After  eight 

^  Weiss  and  Klingelhoeffer,  Klin.  Monatsh.  f.  Augenh.,  March,  1897,  p.  7. 


220  GONOKRHEA 

days  this  trouble  subsided,  but  fifteen  days  later  the  right  ankle  was  affected. 
However,  this  joint  also  recovered  within  eight  days.  The  patient  had 
never  suffered  from  an  inflammation  of  his  urethra. 

Cases  of  this  kind  are,  however,  very  rare.  As  a  rule,  gonorrheal  rheu- 
matism supervenes  upon  a  gonococcal  urethritis,  and  in  particular  upon  an 
inflammation  of  the  posterior  urethra. 

There  is  one  organ  which  appears  to  be  especially  prone  to  act  as  starting- 
point  for  gonorrheal  rheumatism — the  seminal  veside.  Its  thin  walls  and 
its  rich  vascular  supply  render  its  inflammation  very  dangerous,  and  liable 
to  reach  the  blood-stream.  The  vesicle  thus  is  the  organ  from  which  the 
gonococci  are  set  free  and  bring  about  a  pyemia. 

In  practically  every  case  which  I  have  seen  and  followed  up,  I  found 
that  an  inflammation  of  the  seminal  vesicle  preceded  the  outbreak  of  the 
gonorrheal  rheumatism. 

One  of  the  most  striking  examples  I  saw  in  a  man  of  thirty-seven  who 
had  come  to  Paris  from  the  country.  He  acquired  gonorrhea  in  February, 
1911,  was  badly  treated,  and  developed  after  a  time  gonorrheal  rheumatism, 
the  feet,  the  knees,  the  shoulders,  and  the  fingers,  being  involved.  The 
latter  were  more  affected  than  the  other  joints,  and  presented  a  character- 
istic fusiform  shape  (Fournier's  radish  fingers)  when  I  saw  them  in  September, 
1911. 

My  examination  showed  me  that  his  left  seminal  vesicle  was  still — 
i.e.,  seven  months  after  the  beginning  of  the  attack — inflamed,  doughy, 
and  horribly  tender  on  rectal  palpation.  The  vesicle  was  treated,  and 
almost  immediately  all  the  symptoms  showed  a  marked  improvement. 

This  opinion  has  also  been  supported  by  Fuller  of  New  York,  who 
resorts  to  vesiculotomy  as  soon  as  gonorrheal  rheumatism  supervenes.^ 

Whilst  in  man  the  seminal  vesicles  are  the  usual  starting-point  of 
gonorrheal  rheumatism,  systemic  gonococcal  infections  giving  rise  to 
articular  lesions  are  usually  observed  in  women  after  they  have  developed 
a  gonorrheal  salpingitis. 

The  articular  lesions  of  gonorrhea  are  common,  and  usually  make  their 
appearance  between  the  sixth  and  fifteenth  day.  Any  joint  may  be  in- 
volved, but  some  are  attacked  more  often  than  others.  The  most  commonly 
affected  articulations  are,  in  an  order  of  decreasing  frequency:  the  knee, 
the  ankle,  the  wrist,  the  finger- joints  and  toe- joints,  the  elbow,  the  shoulder, 
the  hip,  and  lastly  the  temporo-maxillary  joint. 

Four  main  forms  occur: 

1.  Arthralgia,  characterized  by  articular  pain  only.  A  joint  thus 
affected  shows  nothing  abnormal  when  examined,  and  is  in  no  way  impaired 
in  its  mobility. 

1  Fuller,  La  Clinique,  April  le,  1909,  p.  254;  vide  also  pp.  209  and  222. 


THE  COMPLICATIONS  OF  GONORRHEA  221 

The  pain  is  most  marked  in  the  morning,  when  the  joint  is  shghtly  stiff; 
but  this  stiffness  readily  diminishes  as  the  patient  gets  about,  and  often 
disappears  entirely  during  the  day. 

Several  joints  may  be  affected  in  this  fashion  at  the  same  time,  or  the 
pain  may  be  very  vague  and  shift  to  different  articulations. 

The  character  of  the  pain  varies.  Sometimes  it  is  sharp  and  shifts. 
On  other  occasions  it  is  stationary  and  less  intense,  flaring  up,  however, 
with  every  recrudescence  of  the  affection. 

2.  Hydarthrosis. — This  condition  is  most  often  met  with  in  the  knee, 
and  is  usually  unilateral,  although  it  may  be  bilateral.  The  synovial  sac 
and  its  prolongation  under  the  quadriceps  extensor  are  distended,  the 
joint  is  swollen,  and  the  patella  is  raised  and  separated  from  the  long  bones. 

This  hydarthrosis  takes  a  very  long  time  to  disappear.  It  often  lasts 
two  or  three  months,  and  resists  even  the  most  energetic  medical  treatment. 
Its  main  feature  is  its  stationary  character,  whilst  the  hydarthrosis  of 
rheumatism  is  essentially  a  shifting  one. 

3.  Acute  Arthritis. — This  is  the  most  common  form,  and  is  characterized 
by  violent  pains  affecting  simultaneously  several  joints  (two  or  three  as 
a  rule,  seldom  five  or  six).  It  is  accompanied  by  fever,  which  is  usually 
moderate  (up  to  102-2°).  The  infected  joints  are  extremely  painful,  con- 
siderably swollen,  and  perfectly  useless. 

The  onset  is  abrupt.  A  joint  suddenly  becomes  painful,  and  begins  to 
swell  rapidly.  The  tumefaction  follows  almost  immediately  upon  the 
pain,  the  skin  becomes  red,  and  the  local  temperature  is  raised. 

Acute  gonorrheal  arthritis  seldom  ends  by  resolution.  Its  usual  termina- 
tion is  ankylosis.  Sometimes  suppuration  supervenes,  a  compUcation  of 
the  utmost  gravity  under  the  conditions. 

4.  Polyarthritis  Deformans. — This  type  of  lesion  is  chiefly  found  in 
connection  with  the  small  joints,  with  those  of  the  toes  and  fingers.  The 
articulations  between  the  first  and  second  phalanges  are  often  affected, 
and  thus  a  curious  deformity  which  is  typical  (Fournier's  radish  finger) 
is  brought  about.  In  other  cases  the  metacarpo- phalangeal  joints  or  the 
big  toe-joints  are  impHcated.  In  all  lesions  of  this  kind  atrophy  of  the 
corresponding  muscles  is  common. 

The  diagnosis  of  gonorrheal  rheumatism  is  often  difficult.  The  fact 
that  a  patient  has  had  gonorrhea  previously  should  arouse  one's  suspicions. 
The  chief  signs  which  point  to  a  gonococcal  origin  of  an  attack  of  rheumatism 
are — the  small  number  of  the  joints  involved,  the  fixed  character  of  the 
articular  lesion,  and  the  sudden  inflammatory  exacerbations  in  the  affected 
joints,  which  subside  quickly. 

The  prognosis  is  always  serious,  firstly  because  resolution  is  slow  and 
difficult,  and  secondly  owing  to  the  remarkable  tendency  to  ankylosis. 


-222  .  GONORRHEA 

This  feature  is  typical  of  gonorrheal  articular  lesions,  and  becomes  more 
pronounced  with  every  fresh  attack. 

The  treatment  should  be  directed  against  the  source  of  infection,  and 
ior  this  purpose  it  is  necessary  to  disinfect  the  urethra  as  rapidly  as  possible 
by  means  of  irrigations  with  permanganate  combined  with  massage  of 
the  prostate  and  of  the  seminal  vesicles,  and  also  of  Cowper's  glands  if 
necessary. 

Internal  medication,  sodium  salicylate,  salophen,  aspirin,  etc.,  given 
by  the  mouth,  is  not  very  effective  in  most  cases. 

The  local  treatment  of  the  diseased  joints  is  far  more  important.  The 
diseased  articulations  should  be  immobiHzed  by  means  of  splints  or  plaster 
of  Paris,  and  counter-irritants,  bhsters,  Scott's  dressing,^  or  a  5  per  cent, 
guaiacol  ointment,  should  be  applied.  Electric  treatment  in  the  form  of 
■continuous  currents  or  in  the  shape  of  ionization  with  salicylate  is  often 
beneficial,  chiefly  for  the  relief  of  pain.^ 

When  the  acute  phenomena  have  subsided,  the  normal  mobility  of  the 
parts  should  be  restored  by  means  of  gentle  movements,  electricity, 
massage,  turpentine  baths,  and  hot  baths  (45°  or  50°  C.).^  If  a  marked 
hydarthrosis  is  present,  compression  by  means  of  an  elastic  bandage  or 
puncture  is  often  useful.  Bier's  treatment  in  these  cases  often  gives  good 
results.  Lastly,  there  are  severe  cases  which  require  operative  measures, 
such  as  arthrotomy  or  resection. 

As  gonorrheal  rheumatism  is  cause'd  by  the  action  of  the  gonorrheal 
toxin  on  the  system  after  it  has  been  absorbed  at  the  level  of  the  posterior 
urethra,  one  has  endeavoured  to  find  the  commonest  and  most  important 
places  through  which  the  absorption  into  the  system  takes  place.  The 
seminal  vesicles  are  apparently  most  often  at  fault,  and  the  inflamma- 
tion of  one  or  of  both  of  them  is  most  liable  to  be  followed  by  systemic 
complications. 

For  this  reason  Fuller  of  New  York  treats  gonorrheal  rheumatism  by 
vesiculotomy.  Amongst  his  101  cases  there  was  not  a  single  death  due 
to  the  operation.  In  twenty-three  instances  the  intervention  was  done  for 
gonorrheal  arthritis,  and  in  each  case  a  marked  improvement  followed. 
Saventeen  cases  were  cured  completely  in  this  way.^ 

Unfortunately,  vesiculotomy  is  neither  a  common  nor  an  easy  operation, 
and  thus  it  does  not  seem  likely  that  it  will  ever  find  general  favour. 

Lastly  we  may  mention  that  serum  -  therapy  and  antigonococcal 
vaccination  have  been  resorted  to.     These  therapies  are  based  on  the 

^  Substituted  for  Ung.  Neapolit.  (A.  F.). 

^  Hot  air,  steam,  and  diathermy,  are  also  of  great  service.  In  certain  very  acute 
and  septic  cases  immediate  arthrotomy  and  frequent  irrigation  of  the  joint  cavity  is 
indicated  (A.  F.). 

3  Fuller,  La  Clinique,  April  16,  1909,  p.  254. 


THE  COMPLICATIONS  OF  GONORRHEA  223 

knowledge  that  gonorrheal  rheumatism  is  the  result  of  a  general  pyemia 
due  to  the  gonococcus,  and  seems  to  be  indicated  in  certain  cases  {vide 
Chapter  XI.). 

Muscular  Rheumatism. 

During  an  attack  of  gonorrhea,  pain  in  the  muscles  of  the  loin,  of  the 
neck,  of  the  hollow  of  the  back,  of  the  forearm,  and  in  the  pectoralis  major, 
etc.,  is  occasionally  complained  of.  Up  to  now  medical  men  have  paid  but 
little  attention  to  these  pains ;  they  are,  however,  not  uncommon,  and  seem 
to  be  directly  connected  with  the  gonococcal  infection. 

Gonorrheal  Synovitis. 

Inflammation  of  the  tendon  sheaths  has  been  observed  chiefly  in 
connection  with  the  peronei  muscles  of  the  leg,  the  extensors  of  the  toes 
and  of  the  fingers,  the  muscles  of  the  thumb,  the  radiales,  the  flexors  of  the 
fingers,  the  semitendinosus  and  the  semimembranosus. 

This  gonorrheal  synovitis  is  chiefly  found  in  the  feet,  the  ankle,  the 
knees,  and  the  wrists — that  is  to  say,  in  the  regions  of  those  joints  which 
are  most  often  affected  by  gonorrheal  rheumatism.  These  lesions  are 
characterized  by  a  swelling  and  a  reddening  of  the  integuments  along  the 
course  of  a  tendon  sheath.  The  spontaneous  or  provoked  pain  is  very 
marked,  and  the  voluntary  movements  are  difiicult  or  impossible. 

Bacteriological  researches  have  demonstrated  the  presence  of  gonococci 
in  cases  of  suppurative  tenosynovitis. 

Griffon^  has  published  the  history  of  a  patient  in  whom  the  bursa  of 
the  tensor  fasciae  femoris  was  inflamed.  Puncture  yielded  a  distinctly 
purulent  fluid  in  which  the  direct  examination  and  the  cultures  on  blood- 
agar  showed  the  presence  of  gonococci.  When  a  second  puncture  was 
made  twenty-four  hours  later,  no  more  diplococci  were  found  in  the  pus, 
but  the  culture  gave  a  positive  result.  Lastly,  the  material  obtained  from 
a  third  puncture  a  few  days  later,  showed  no  gonococci  under  the  microscope 
or  in  cultures. 

This  observation  is  interesting  in  so  far  as  it  proves  how  easily  the  gono- 
coccal nature  of  these  affections  can  be  overlooked,  unless  the  bacterio- 
logical examination  be  made  immediately. 

Gonorrheal  Bursitis. 

Inflammation  of  the  bursse  is  less  frequent.  The  bursae  most  com- 
monly involved  are  the  retro-  and  subcalcanean  bursae. 

The  pain  in  the  heel  (talalgia),  which  is  so  frequently  observed  during 
^  Griffon,  Revue  de  Medecine,  January  10,  1901,  p.  84. 


224  GONORKHEA 

an  attack  of  gonorrhea,  is  in  some  cases  due  to  their  inflammation.  But. 
as  Fournier  and  Jacquet  have  pointed  out,  gonorrheal  talalgia  is  more  often 
the  result  of  an  osteitis  or  of  an  osteo-fibrous  calcanean  rheumatism. 


Gonorrheal  Periostitis. 

This  complication  of  gonorrhea  has  been  chiefly  studied  by  Fournier. 
As  a  rule,  the  patients  complain  of  a  sharp  pain  in  a  bone,  which  is  definitely 
limited  to  a  small  area  of  the  size  of  a  shilhng  or  less. 

It  is  not  uncommon  to  find  at  this  level  a  slight  doughy  swelhng,  and 
sometimes  an  inflammatory  reddening  of  the  integuments.  After  a  few 
days'  duration  these  phenomena  subside  and  disappear.  The  parts  most 
commonly  involved  are  the  tibia,  the  epitrochlea,  the  lower  end  of  the 
ulna,  the  upper  end  of  the  fibula,  etc.,  or,  in  a  few  words,  the  bony  projections 
of  the  skeleton. 

In  certain  cases  these  periostites  do  not  terminate  by  resolution,  but 
form  true  tumours  which  become  periostoses.  They  are  flattened,  fixed; 
hard,  small,  resistant  swellings  firmly  adherent  to  the  bone.  At  first  they 
give  rise  to  a  certain  amount  of  pain,  but  they  soon  become  less  and  less 
sensitive. 

Abscesses  containing  Gonococci. 

Systemic  gonococcal  infection  is  occasionally  followed  by  the  forma- 
tion of  abscesses  which  contain  gonococci  in  their  pus.  Cases  of  this  kind 
have  been  described  by  Sahli,  Lang  and  Paltauf,  Horwitz,  etc. 

Cassel  has  seen  an  infant  who  developed  purulent  ophthalmia  shortly 
after  birth,  and  subsequently  gonorrheal  rheumatism  and  an  abscess  on 
his  back.  This  abscess  was  incised,  and  the  bacteriological  examination 
of  the  pus  revealed  the  presence  of  the  gonococcus  in  a  state  of  purity.^ 

Dr.  Campbell^  has  published  the  case  of  a  youth  of  eighteen  who  sus- 
tained a  compound  fracture  whilst  he  was  suffering  from  an  attack  of 
gonorrhea  which  he  had  acquired  six  weeks  previously.  Considerable 
suppuration  set  in  at  the  site  of  the  fracture,  and  the  pus  yielded  cultures 
which  contained  gonococci.  Dr.  Campbell  holds  that  in  this  case  the 
fracture  was  infected  by  cocci  which  reached  it  through  the  blood-stream. 

Kerassotis^  has  seen  a  metastatic  gonorrheal  abscess  in  a  man  of  twenty- 
five  who  was  suffering  from  a  gonorrheal  urethritis,  and  subsequently 
developed  an  abscess  in  the  mastoid  region.  The  pus  collected  after  it 
had  been  incised  contained  gonococci.    Both  the  urethritis  and  the  abscess 

1  Cassel,  Presse  Medicale,  August  8,  1903,  p.  569. 

2  New  York  Medical  Journal,  February  28,  1908. 

3  Kerassotis,  Ann.  Genito-Urin.,  1904,  p.  516. 


THE  COMPLICATIONS  OF  GONORRHEA  225 

were  cured  at  the  same  time.     It  was  thus  clear  that  one  was  deaUng  with 
a  metastatic  gonococcal  abscess  which  owed  its  origin  to  the  urethritis. 

M.  Meyer  1  has  shown  at  the  Berlin  Medical  Society  a  patient  who 
suffered  from  a  profuse  vaginal  discharge  containing  gonococci,  and  developed 
a  superficial  whitlow  on  her  right  middle  finger  a  few  days  after  she  had 
scratched  it  whilst  she  was  cleaning  saucepans.  A  big,  slightly  raised  bleb, 
containing  a  yellowish  fluid,  made  its  appearance  on  the  outer  surface  of  the 
finger,  which  was  incised.  The  pus  withdrawn  from  it  contained  gonococci, 
as  the  microscope  and  cultures  showed. 

Effects  of  Gonorrhea  upon  the  Skin. 

Gonorrheal  skin  lesions  are  chiefly  found  in  men,  and  are  usually  noticed 
about  the  fourth  or  flfth  week  of  the  infection. 
The  following  forms  have  been  described: 

1 .  Erythemata,  which  imitate  measles  or  scarlet  fever. 

M.  Hodara  quotes  the  case  of  a  soldier  who  developed  on  the  third  day 
of  his  urethral  discharge  an  eruption,  and  therefore  sought  admission  to 
the  hospital. 

There  it  was  found  that  his  chest,  face,  arms,  and  legs  were  covered 
with  an  eruption  composed  of  rounded  and  polymorphous  erythematous 
patches.  He  had  fever  (102-9°  F.),  and  within  forty-eight  hours  the 
erythema  had  become  general  and  assumed  a  bullous  character.  The 
various  bullge  were  filled  with  a  purulent  Hquid,  which  in  some  instances 
was  blood-stained.  His  face,  which  was  remarkably  red,  became  edematous, 
and  conjunctivitis  supervened.  Gradually  the  various  patches  underwent 
desquamation,  and  the  bullae  were  superseded  by  scabs.  The  fever  re- 
mained at  102°  F.  for  eleven  days,  and  the  patient  was  very  depressed  and 
feeble. 

The  nature  of  the  complaint  remained  obscure  for  a  week,  until  the 
author  made  cultures  from  the  blood,  which  revealed  the  presence  of  the 
gonococcus.     This  organism  was  then  also  found  in  the  urethra.^ 

2.  Purpura,  which  is  found  chiefly  on  the  lower  limbs,  and  seldom 
spreads  beyond  the  knees.  This  gonorrheal  purpura  is  also  met  with  on 
mucous  surfaces,  on  the  arch  of  the  palate,  on  the  soft  palate,  and  in  the 
larynx. 

General  malaise  and  other  systemic  disturbances  usually  accompany 
this  purpura  and  suggest  typhoid  fever.  The  duration  of  this  eruption 
is  very  variable,  from  twenty-four  hours  to  three,  four,  or  ten  days,  accord- 
ing to  the  case. 

The  diagnosis  is  often  difficult.     A  patient  whom  I  saw  together  with 

^  Meyer,  Presse  Medicale,  August  8,  1903,  p.  562. 
2  Qaz.  Med.  d'Orient,  No.  4,  1912,  p.  142. 

15 


226  GONOKEHEA 

Dr.  Alexandre  had  a  rebellious  attack  of  gonorrhea,  whicli  was  complicated 
by  well-marked  gonorrheal  littritis.  Whilst  under  treatment  he  suddenly 
developed  a  marked  eruption,  which  another  medical  man  who  was  called 
in,  diagnosed  as  a  syphilitic  roseola  (!),  although  he  had  never  had  any  trace 
of  syphilis. 

It  need  hardly  be  mentioned  that  in  these  cases  drug  rashes,  such  as 
copaiba  eruptions,  have  to  be  excluded  before  one  can  pronounce  the  skin 
lesions  to  be  due  to  the  gonococcus.  But  it  would  seem  as  if  even  in  these 
instances  the  organism  were  often  at  fault,  and  not  the  drug. 

3.  Gonorrheal  Keratoses. — The  gonorrheal  keratoses  consist  of  more  or 
less  pronounced  horny  crusts,  as  described  by  Vidal,  Jeanselme,  Jacquet, 
and  Chauffard.     They  have  been  carefully  studied  recently  by  Le  Damany.^ 

Vidal  was  the  first,  in  1893,  to  draw  attention  to  a  dermopathy  which 
he,  and  since  then  Jeanselme,  Jacquet  and  Eobert,  and  Chauffard  have 
described  under  the  name  of  "  corne  cutanee."  It  is  characterized  by 
trophic  changes  in  the  skin,  which  appear  to  be  in  relation  with  gonorrhea. 

They  make  their  appearance  three  to  five  weeks  after  the  beginning  of 
the  infection,  and  are  almost  exclusively  found  in  cases  which  present  serious 
complications.  Their  aspect  is  that  of  a  corn,  or  of  a  conical  protrusion 
or  of  a  large  hard  irregular  patch,  composed  of  hypodermic  horny  masses. 
As  a  rule,  these  hyperkeratinized  areas  are  remarkably  symmetrical.  They 
are  chiefly  found  on  the  limbs,  especially  on  the  palmar  surfaces  of  the 
hands  and  on  the  plantar  aspect  of  the  feet.  They  may,  however,  occur 
anywhere,  even  on  the  face,  on  the  scalp,  and  on  the  genitals.' 

According  to  Professor  Chauffard,  this  skin  disease  is  due  to  an  exalted 
and  cachexia-producing  virulence  of  the  gonococcal  infection,  which  leads 
to  trophic  disturbances.  The  lesions  remain  stationary  for  a  very  long 
time,  and  often  recur  if  the  patient  is  unfortunate  enough  to  get  a  fresh 
attack  of  gonorrhea. ^ 

Cardiac  Complications  of  Gonorrhea. 

The  cardiac  complications  of  gonorrhea  are  by  no  means  exceptional, 
as  more  than  100  cases  are  to  be  found  in  the  literature.  They  are  more 
common  in  men  than  in  women,  and  are  usually  observed  during  the  acute 
stage  of  the  discharge. 

1.  Gonococcal  Endocarditis. — Its  onset  is  sometimes  sudden  and 
characterized  by  fever  or  by  syncope,  but  in  most  cases  its  beginnings  are 
insidious,  and  careful  auscultation   has  to  be  resorted  to  in  order  to  find 

^  Le  Damany,  Presse  Medicate,  June  19,  1897,  p.  282. 

2  Local  treatment  of  these  lesions  is  practically  useless.  They  often  improve  after 
the  urogenital  lesions  have  been  cured.  It  is  satisfactory  to  note  that  vaccine-therapy 
appears  to  have  a  favourable  effect  on  them  {vide  Lancet,  May  17,  1913,  p.  1382  (A,  P.j. 


THE  COMPLICATIONS  OF  GONORKHEA  227 

any  characteristic  murmur.  When  estabhshed,  the  disease  can  be  diagnosed 
by  the  presence  of  abnormal  heart  sounds  (murmur  and  duplicated  sound). 
The  valve  most  often  affected  is  the  mitral,  but  the  aortic  valves  are  also 
frequently  damaged.  Functional  troubles  and  general  symptoms  may 
be  wanting.  The  acute  stage  is  comparatively  short,  but  it  often  leaves 
incurable  permanent  lesions. 

Widal  and  Faure-BeauHeu^  have  brought  before  the  Medical  Society 
of  the  Paris  Hospitals  a  case  of  gonorrheal  endocarditis  in  which  the  gono- 
coccus  was  isolated  from  the  blood  during  hfe,  and  found  on  the  affected 
heart  valve  after  death. 

This  double  finding — in  the  blood  during  life,  and  on  the  valve  post 
mortem — leaves  no  doubt  as  to  the  authentic  character  of  the  case,  and 
proves  conclusively  that  there  is  such  a  disease  as  gonococcal  septicemia. 

A.  Rendu  and  J.  Halle  ^  have  published  the  case  of  a  woman  of  thirty 
who,  having  contracted  gonorrhea,  developed  a  metritis,  and  later  on  a 
periarthritis  at  the  elbow.  Her  general  condition  rapidly  became  worse. 
A  hectic  fever  indicative  of  the  generahzation  of  the  infection  supervened, 
and  the  patient  died  within  a  short  time.  The  autopsy  showed  that  the 
patient  had  been  suffering  from  a  gonorrheal  metritis,  the  uterine  mucus 
contained  gonococci,  and  the  serous  fluid  obtained  from  the  ceUuhtis  at 
the  elbow  yielded  a  pure  culture  of  Neisser's  organism.  On  the  other 
hand,  it  was  impossible  to  find  any  gonococci  in  the  blood  or  in  the  pleural 
and  peritoneal  exudates.  However,  the  bacteriological  and  histological 
findings  were  again  positive  when  the  aortic  valves  were  examined.  The 
chief  cardiac  lesion  found  at  the  autopsy  was  an  infective  endocarditis. 
The  aortic  valve  was  enormously  thickened,  and  covered  at  its  free  border 
by  cauHflower-hke  vegetations. 

This  case  alone  would  suffice  to  prove  the  existence  of  an  mfective 
endocarditis  caused  exclusively  by  the  gonococcus. 

Carageorgiades  ^  has  collected  a  dozen  cases  of  gonococcal  endocarditis. 
The  autonomy  of  this  disease  is  proved  by  the  fact  that  the  gonococcus 
can  be  found  on  the  cardiac  valves.  Only  those  cases  should,  however,  be 
diagnosed  as  gonococcal  in  which  the  presence  of  the  gonococcus  can  be 
demonstrated. 

Prockoska^  has  pubhshed  the  case  of  a  young  man  of  twenty-four  who, 
during  an  attack  of  gonorrhea,  was  taken  ill  with  fever,  swelhng  of  his 
joints,   and  ulcerative  endocarditis  affecting  his  aortic  valves.     The  ex- 

^  Widal  and  Faure-Beaulieu,  8oc.  Med.  des  Hop.,  June  30,  1905. 

2  A.  Rendu  and  J.  Halle,  Soc.  Med.  des  Hop.,  November  12,  1897. 

3  Carageorgiades,  De  V Endocardite  Gonococcique  (Thesis,  Paris,  1896). 

*  Prockoska,  "  tjber  die  GonorrhoischeAllgemein- Infection,"  Virchoio's  Arch.,  1901, 
vol.  c]xiv.,  p.  492. 


228  GONOEKHEA 

animation  of  the  blood  during  life  failed  to  show  any  gonococci.  The 
patient,  however,  succumbed  in  a  fortnight,  and  at  the  autopsy  an  ulcera- 
tive endocarditis  was  found.  Pieces  of  the  aortic  valves  and  blood  taken 
from  the  heart  were  inoculated  in  tubes,  and  yielded  cultures  of  gonococci. 

Frendl^  treated  a  heutenant  of  twenty  who,  during  the  third  week 
of  his  gonorrhea,  was  suddenly  taken  ill  with  dyspnea  and  precordial 
pain.  He  died  forty- eight  hours  after  his  admission  to  the  mihtary  hospital, 
his  temperature  rising  to  40°  C. 

At  the  autopsy  his  pericardium  was  found  to  be  filled  with  a  sero- 
purulent  fluid;  the  aortic  valves  were  perforated,  and  showed  a  typical 
ulcerative  endocarditis.  Microscopic  examination  and  cultures  on  agar- 
serum  demonstrated  the  presence  of  gonococci  in  a  state  of  purity. 

Wassermann^  has  also  published  a  conclusive  case. 

A  young  man  of  twenty-seven  who  had  acquired  his  fourth  attack  of 
gonorrhea  suffered  from  prostatitis  and  retention,  which  necessitated  the 
passing  of  a  catheter.  This  intervention  was  followed  by  a  serious  general 
illness,  and  led  to  a  fatal  termination.  The  autopsy  showed  an  abscess  in 
the  left  lobe  of  the  prostate,  a  nephritis  in  its  early  stage,  and  cystitis  with 
ecchymoses  on  the  mucosa.  The  left  ventricle  of  the  heart  was  hyper- 
trophied,  and  the  aortic  valves  were  studded  with  warty  growths  which 
contained  gonococci,  as  the  microscopical  examination  showed.  Cultures 
confirmed  this  histological  diagnosis  by  yielding  pure  cultures  of  Neisser's 

organism. 

Sidney,  Thayer,  and  Lazear,^  quote  two  cases  of  gonorrheal  endocarditis  : 

The  first  one  relates  to  a  woman  of  thirty-four  who  had  rheumatic 
pains  for  three  months.  Cultivation  of  the  blood  showed  gonococci.  The 
post-mortem  examination  revealed  a  vegetating  endocarditis  affecting  the 
mitral  valve.  The  valvular  thrombi,  as  well  as  the  vagina  and  the  uterus, 
contained  gonococci. 

The  second  observation  relates  to  a  young  man  of  nineteen  who  had 
had  gonorrhea  for  six  months.  Auscultation  revealed  an  aortic  systohc 
murmur  and  a  prolonged  first  sound  at  the  apex.  A  blood-culture  yielded 
typical  gonococci.  At  the  autopsy  the  pericardium  was  found  to  contain  300 
grammes  of  liquid  in  which  gonococci  were  present.  On  the  middle  segment 
of  the  mitral  valve  a  thrombus  was  present  which  also  contained  gonococci. 

Endocarditis  is  by  far  the  commonest  cardiac  complication  of  gonorrhea, 
and  is  usually  preceded  by  articular  lesions. 

Histolof^ically,  its  lesions  are  those  of  a  simple  or  of  an  ulcerative  endo- 

1  Frendl,  Wien.  Klin.  Woch.,  1903. 

2  Wassermann,  Miinch.  Med.  Woch.,  1901,  p.  298. 

3  Sidney,  Thayer,  and  Lazear,  Journal  of  Experimental  Medicine,  1899,  vol.  vi.. 
No.  1,  p.  81. 


THE  COMPLICATIONS  OF  GONORRHEA 


229 


carditis  with  destruction  and  perforation  of  the  valves.     The  right  heart 
is  often  involved 

In  the  thirty- one  cases  collected  by  Sidney,  Thayer,  and  Lazear,  the 
lesions  were  distributed  as  follows : 


/"Aortic 
Left  heart     J  Mitral 
[Both 

Right  heart /P"l^^°^.^;y 

Both  hearts 


12^ 

6  -  67-7  percent. 
3 


I}- 


25-8 
2        6-4 


Gonorrheal  endocarditis  affects  chiefly  adults,  and  in  particular  men. 
Its  onset  may  occur  at  any  time— *.e.,  soon  after  the  gonorrhea  has  been 
acquired,  or  even  after  years. 

2.  Gonococcal  Pericarditis. — This  disease  is  far  less  common,  and  takes 
occasionally  a  very  mild  course.  In  most  cases,  however,  it  is  characterized 
by  definite  symptoms:  palpitations,  precordial  pain,  and  dyspnea.  The 
physical  signs  are  those  of  a  dry  pericarditis  (pericardial  rub)  or  of  a  peri- 
carditis with  effusion  (more  or  less  increased  cardiac  dulness,  heart  sounds 
faint,  pulse  small  and  irregular).  The  affection  is  usually  benign,  and 
terminates,  as  a  rule,  by  resolution. 

3.  Gonococcal  Myocarditis. — This  variety  of  myocarditis  is  never  found 
alone.  It  is  always  associated  with  endocarditis,  and  is  a  sequela  of  the 
latter  or  of  pericarditis.  The  findings  of  morbid  anatomy  have  estabhshed 
beyond  doubt  that  the  gonococcus  migrates  into  the  endocardium  and  into 
the  myocardium. 

One  finds  in  the  latter  areas  of  leucocytic  infiltration,  embolic  abscesses, 
and  necrotic  patches,  which  contain  gonococci. 

Pericarditis  usually  disappears  without  leaving  a  trace.  Endocarditis 
also  terminates  in  most  cases  by  recovery,  but  it  frequently  leaves  common 
valvular  lesions.  It  may  give  rise  to  embohsm,  as  is  shown  by  two  cases 
recorded  in  the  literature. 

The  treatment  of  the  cardiac  complications  of  gonorrhea  is  purely 
symptomatic.  The  patient's  strength  must  be  maintained  by  means  of 
stimulants.  Counter-irritants  applied  to  the  precordial  region  are  often 
of  value,  and,  according  to  the  requirements  of  the  case,  the  usual  heart 
tonics  and  regulators  of  the  circulation  should  be  prescribed. 


Complications  of  Gonorrhea  affecting  the  Digestive  System. 

The  gonococcus  can  invade  all  parts  of  the  alimentary  canal,  but  true 
gonorrheal  complications  appear  to  occur  only  at  its  two  extremities — 
namely,  at  the  mouth  and  at  the  ano-rectal  region.     The  esophagus,  the 


230  GONOEEHEA 

stomach,   and  the   intestine  do  not  seem  to  be  inconvenienced  by  the 
gonococcus. 

An  interesting  observation  of  Tazembre^  appears  to  bear  out  this 
statement. 

A  husband  who  had  been  betrayed,  wished  to  punish  his  wife  and  her 
lover  by  infecting  them  with  gonorrhea,  and  contracted  the  disease  especially 
for  that  purpose.  But  instead  of  contaminating  his  wife  in  the  usual  way, 
he  conceived  the  extraordinary  idea  of  compelling  her  to  drink  every  day 
for  a  week  or  so  a  certain  quantity  of  milk  which  he  had  mixed  with  as 
much  pus  as  he  could  obtain  from  his  urethra.  After  a  certain  time  both 
the  wife  and  her  sweetheart  contracted  the  disease,  but  they  never  dis- 
played any  symptoms  pointing  to  an  inflammation  of  the  mucous  lining 
of  the  aUmentary  canal.  It  thus  seems  probable  that  the  absorption  of 
gonorrheal  virus  with  the  food  has  no  detrimental  effect  upon  the  digestive 
tract. 

Prostitutes  are  commonly  addicted  to  vicious  habits  (cunniHngus). 
and  yet  they  do  not  display  any  digestive  disturbances  in  consequence. 

Gonorrhea  Buccalis. — This  complication  is  much  less  frequent  than 
gonorrheal  proctitis.     Its  existence  is,  however,  beyond  doubt. 

Horand  related  in  1885  a  demonstrative  case:  A  medical  student 
practised,  during  the  absence  of  his  sweetheart,  a  coitus  buccalis  with  a 
prostitute,  and  developed  three  days  later  a  typical  attack  of  gonorrhea, 
which  lasted  two  weeks.  Gonococci  had  been  found  in  the  discharge. 
After  he  had  been  cured,  he  induced  his  mistress  to  lend  herself  to  the  same 
vice,  and  no  ill-effect  resulted.  It  was  thus  clear  that  the  gonorrhea  was 
really  due  to  an  infection,  and  not  merely  the  product  of  mechanical  irrita- 
tion or  a  recrudescence  of  an  old  gonorrhea. 

Guttler  in  1889  published  the  case  of  a  woman  who  developed  a  pseudo- 
membranous stomatitis  after  a  coitus.  The  false  membranes  contained 
gonococci,  and  the  individual  with  whom  she  had  had  relations  suffered 
from  typical  gonorrhea. 

Petit  in  1889,  Honnora  in  1889,  Colombini  in  1901,  and  Jurgens  in 
1904,  have  each  described  cases  of  gonorrheal  stomatitis  which  were  charac- 
terized by  a  swelling  of  the  tongue,  by  greyish,  more  or  less  rounded  spots 
on  the  buccal  mucous  membrane,  and  by  a  fetid  breath. 

Buccal  gonorrhea  is  comparatively  frequent  in  the  new-born,  especially 
when  they  have  already  become  the  prey  of  ophthalmia.  This  inflamma- 
tion of  the  mouth  is  apt  to  become  very  serious,  as  a  pyemia  may  supervene. 
Ahlfeld  has  seen  infants  in  whom  the  palate  was  covered  with  a  thick 
coating,  and  studded  with  yellowish  masses  which  contained  a  great  number 
of  gonococci. 

^  Tazembre,  Archiv.  de  Med.,  2nd.  series,  vol.  ii. 


THE  COMPLICATIONS  OF  GONORRHEA  231 

Kimball  of  New  York  described  in  1903  a  case  of  gonococcal  pyemia 
which  had  its  starting-point  in  the  mouth.  There  was  no  sign  of  any 
ophthalmia,  or  rhinitis,  or  vulvitis.  The  gonococcus  was  present  in  the 
blood  and  in  the  pus. 

Chantemesse^  has  published  the  case  of  a  foreigner  who  developed  ten 
days  after  a  coitus^  "  ab  ore  "  a  urethral  discharge  which  contained  a  great 
number  of  gonococci. 

Von  Geissler^  quotes  a  similar  case.  His  patient  developed  a  gono- 
coccal urethritis  with  positive  microscopic  findings  four  days  after  a  coitus 
"  ab  ore."     He  had  never  had  gonorrhea  previously. 

In  cases  of  this  kind  the  gonococci  are  often  deposited  in  the  mouth, 
which  receives  them  for  the  moment  without  showing  any  reaction,  and 
the  infective  material  can  be  taken  over  by  a  second  individual  who  is 
addicted  to  the  same  vice. 

I  have  met  with  a  very  typical  instance.  A  young  man  who  was  about 
to  get  married,  and  who  on  that  account  had  broken  off  his  relations  with 
his  mistress,  who  had  lived  with  him  for  six  years,  went  to  a  brothel  a  few 
days  before  the  wedding  was  to  take  place.  He  practised  a  coitus  "  ab 
ore  "  in  order  "  to  safeguard  himself  against  any  possible  infection,"  as 
he  told  me.  Four  days  later  he  had  a  profuse  discharge  in  which  I  found, 
to  his  great  surprise,  a  considerable  number  of  typical  gonococci.  He 
had  never  had  any  inflammation  of  his  urethra  previously. 

Occasionally,  however,  the  reaction  set  up  by  the  gonococcus  in  the 
buccal  cavity  is  intense.  Thus,  Malherbe^  of  Nantes  met  with  a  case  of 
gonorrhea  buccalis  in  which  an  intense  stomatitis  developed,  which  was 
accompanied  by  violent  pain  and  the  impossibility  of  swallowing.  The 
pus  contained  gonococci,  and  the  buccal  mucous  membrane  was  smooth, 
as  if  it  were  varnished.  The  lips  were  covered  with  a  large  number  of 
small,  irregular,  superficial  ulcerations,  and  the  gums  were  edematous 
and  loose  around  the  margin  of  the  teeth.  At  these  places  there  was  a  good 
deal  of  pus.  The  hard  and  the  soft  palates  were  red,  but  not  inflamed. 
Buccal  irrigations  with  a  1  :  4,000  solution  of  potassium  permanganate, 
and  painting  the  ulcerations  with  a  2  per  cent,  solution  of  chromic  acid 
in  water,  gave  great  relief,  and  effected  a  cure  in  five  days. 

Jurgens^  has  published  a  case  of  gonorrheal  stomatitis  in  an  adult  in 
which  the  bacteriological  examination  established  its  true  nature.  The 
lesions  were  most  marked  at  the  free  border  of  the  gums,  which  were  covered 
by  a  greenish-grey  deposit  and  were  horribly  fetid.      The  buccal  mucous 

1  Soc.  Med.  des  Hop.,  July  10,  1891. 

2  Von  Geissler,  Wien.  Klin.  Rundschau,  No.  21,  1908. 

3  Oaz.  Med.  de  Nantes,  October  14,  1911. 

*  Jurgens,  Bed.  Klin.  Woch.,  No.  24,  June  14,  1904. 


232  GONOKKHEA 

membrane  was  swollen,  inflamed,  and  so  painful  that  the  patient  experienced 
great  difiiculty  in  opening  and  closing  his  mouth.  Salivation  was  so  free 
that  the  pillow  was  saturated  overnight.  Improvement  was  only  obtained 
after  apphcations  of  a  0-15  per  mille  solution  of  corrosive  sublimate  had 
been  resorted  to.  After  repeated  bacteriological  researches,  a  diplococcus 
was  ultimately  found  which  showed  the  typical  intracellular  arrangement 
of  the  gonococcus.     Cultivation  on  Wertheim's  medium  was  also  positive. 


Ano-Rectal  Gonorrhea. 

The  history  of  ano-rectal  gonorrhea  has  been  described  by  Mermet.^ 

Bumni  in  1884  was  the  first  to  demonstrate  the  presence  of  gonococci 
in  a  purulent  discharge  from  the  rectum. 

Horand  in  1888  observed  eight  cases  of  gonorrheal  proctitis  in  which 
the  disease  had  been  caused  by  direct  spreading. 

Frisch  in  1891  made  post-mortem  examinations  of  individuals  who 
had  been  sufiering  from  rectal  gonorrhea  for  six  months,  and  found  gonococci 
not  only  in  the  pus,  but  also  in  sections  of  the  rectum. 

Tuttle  in  1892  published  three  cases  of  gonorrheal  rectitis  in  which 
the  pus  contained  gonococci. 

Hartmann  in  1895  quoted  a  case  of  gonorrheal  ulceration  of  the  anus 
with  positive  bacteriological  findings. 

Griffon  2  has  reported  the  case  of  a  youth  of  nineteen  in  whom  gonococci 
were  found  by  direct  examination. 

Dr.  Julhen,^  who  is  an  authority  on  this  subject,  holds  that  ano-rectal 
gonorrhea  occurs  in  5  per  cent,  of  all  cases.  It  is  much  more  common  in 
women  than  in  men. 

Its  causation  is  either  indirect  or  direct. 

1.  Indirect  Causes. — Ano-rectal  gonorrhea  is  most  commonly  the  result 
of  the  presence  of  a  gonococcal  focus  in  the  neighbourhood  of  the  terminal 
gut.  In  women,  especially  when  they  lie  on  their  back,  the  gonorrheal 
discharge  runs  along  the  perineum,  as  it  flows  from  the  vulva,  and  thus 
reaches  the  anus.  This  organ  collects  the  infectious  material,  owing  to 
its  funnel  shape — a  very  favourable  condition  for  contamination. 

Indirect  contagion  is  also  met  with  under  other  circumstances.  For 
instance,  women  have  been  known  to  infect  themselves  by  taking  an  enema 
through  a  cannula  which  had  been  used  previously  for  a  vaginal  douche  by 
some  other  woman  who  was  suffering  from  gonorrhea. 

1  Mermet,  Gazette  des  Hopitaux,  May  2,  1896,  No.  52,  p.  531. 

2  Griffon,  "  Rectite  a  Gonocoques,"  Presse  Medicale,  February  13,  1897. 

3  JuUien,  "  Les  Blennorragies  Aberrantes,"  Bev.  Int.  de  Med.  et  de  Ghir.,  April, 
1905. 


THE  COMPLICATIONS  OF  GONOEKHEA  233 

Rollet  has  reported  the  story  of  a  man  who  was  afflicted  with  chronic 
constipation,  and  was  in  the  habit  of  introducing  his  index  into  his  rectum 
in  order  to  ehcit  defecation.  This  patient  acquired  gonorrhea,  and  subse- 
quently inoculated  his  rectum  with  his  finger. 

2.  Direct  Causes. — Very  often  ano-rectal  gonorrhea  is  the  result  of 
direct  contamination  through  a  coitus  contra  natiiram  (sodomy).  JuUien 
quotes  the  following  case:  "Two  friends,  Orestes  and  Pylades,  wished  to 
honour  the  same  lady.  Orestes,  who  knew  himself  to.  be  impure,  was 
reluctant  to  soil  the  sanctum  which  Pylades  should  enter  later  on.  He 
therefore  worshipped  Venus  Callypyge,  as  he  did  not  wish  to  divulge  his 
secret  or  to  betray  his  friend.  Pylades,  who  suspected  Orestes,  thought 
it  wise  to  be  cautious.  He  therefore  discarded  the  normal  ritual  and 
followed  his  friend's  example.  He  was  severely  punished  for  his  sin,  and 
long  after  Orestes  had  forgotten  his  error,  he  continued  to  shed  bitter 
tears." 

Dr.  Verchere  has  had  many  occasions  during  his  visits  to  Saint-Lazare 
to  convince  himself  of  the  great  spread  of  sodomy.  There  are  but  few 
prostitutes,  if  any,  who  resist  against  these  revolting  practices.  They 
unanimously  state  that  hardly  a  day  passes  without  some  client  asking  for 
this  "  favour."  Some  day  or  other  they  all  yield,  enticed  by  the  prospect 
of  a  larger  present,  and  the  majority  of  them,  finally  allow  their  rectum 
and  anus  to  be  traumatized  daily. ^ 

Dr.  Picker^  has  paid  much  attention  to  the  gonococcal  infections  of 
the  rectum  which  supervene  upon  abscesses  of  Cowper's  glands,  of  the 
prostate,  and  of  the  seminal  vesicles.  He  notes  that  in  rectal  infections 
of  this  kind  the  symptoms  are  often  painful,  consisting  of  a  burning  pain 
in  the  anus  at  the  end  of  micturition  or  during  defecation. 

As  a  rule,  ano-rectal  gonorrhea  is  characterized  by  a  complete  absence 
of  subjective  symptoms.  The  patients  make  no  complaint,  they  have 
no  pain,  and  only  become  aware  of  their  nialadv  if  they  look  for  it  care- 
fully. 

Brunswic^  has  called  attention  to  this  point.  It  is  a  great  mistake 
to  expect  the  anal  and  peri- anal  tissues  to  be  bathed  in  pus,  and  to  be 
violently  inflamed  and  excoriated.  One  sees  no  pus,  and,  in  order  to  find 
it,  it  is  necessary  to  explore  the  rectum  with  the  finger.  The  discharge 
in  no  way  resembles  that  of  ordinary  gonorrhea,  which  is  creamy  and  yellow.. 
It  is  brownish,  and  the  gonococcus  is  seldom  found  in  it  amongst  the  huge 
number  of  other  micro-organisms  present. 

^  Verchere,  De  la  Blennorragie  chez  la  Femme,  Paris  (RuefE),  1894. 

2  Picker,  Centralb.  f.  d.  Kranhh.  der  Sexual  Organe,  vol.  xvi.,  November  21,  1905. 

3  Brunswic-le-Bihan,  "La  Blennorragie  Rectale,"  Bidl.  Acad,  de  Med.,  1907, 
p.  501. 


234  GONOEEHEA 

In  tlie  jflorid  state  three  important  signs  characterize  ano-rectal  gonor- 
rhea, as  Jullien  has  pointed  out — namely: 

1.  The  dro'p,  which  does  not  reach  the  anal  orifice.  In  women  it  should 
be  sought  for  by  introducing  the  finger  into  the  vagina,  and  pressing  from 
above  downwards  on  the  recto-vaginal  septum.  Pus  containing  gonococci 
may  thus  be  obtained. 

2.  The  fissure,  which  is  to  be  found  at  the  posterior  end  of  the  anus. 
It  is  a  narrow,  superficial  fissure  which  is  usually  hidden  in  a  fold  of  mucous 
membrane.  It  seldom  gives  rise  to  bleeding,  and  takes  a  slow  and  in- 
definite course. 

3.  The  condyloma,  which  is  single,  prominent,  and  elongated.  It  is 
thin,  shiny,  very  soft,  and  almost  painless.  It  is  the  reveaUng  sign  far 
excellence  of  ano-rectal  gonorrhea. 

Amongst  the  frequent  sequelcB,  collections  of  pus  around  the  ano-rectal 
passage  and  strictures  deserve  a  special  mention.  The  latter  are  only  too 
readily,  and  without  any  justification,  labelled  "  syphihtic." 

Brunswic-le-Bihan ^  recognizes  three  important  complications: 

1.  Acute  Perirectitis,  which  is  really  an  ischio-rectal  abscess  and  has  the 
features  of  such.  In  the  pus  only  B.  coli  and  other  members  of  the  flora 
of  the  lower  bowel  are  found.  The  role  of  the  gonococcus  is  restricted 
to  damaging  the  rectal  epithehum.  In  this  way  a  passage  is  made  for 
the  other  organisms,  but  the  gonococcus  itself  does  not  penetrate  into  the 
ischio-rectal  fossa  [or,  if  it  does,  it  succumbs  very  rapidly  (A.  F.)]. 

2.  Chronic  Perirectitis  is  characterized  by  the  formation  of  a  firm,  hard, 
sometimes  almost  cartilaginous  sheath  around  the  rectal  walls,  which 
grips  them  hke  a  vice.  It  forms  a  more  or  less  complete  ring  of  variable 
width  around  the  terminal  gut,  and  produces  a  more  or  less  noticeable 
bulging  into  the  lumen  of  the  rectum.  This  condition  gives  rise  to  a  series 
of  functional  troubles,  and  is  most  tenacious  and  rebellious.  One  notes 
a  heavy  feeling  about  the  rectum,  or  a  sensation  as  if  the  gut  contained 
a  foreign  body,  tenesmus,  defecation  troubles,  difiiculty  in  and  pain  on 
emptying  the  rectum,  and  all  the  symptoms  of  rectal  coarctation. 

3.  Gonorrheal  Strictures  of  the  Rectum.^ — This  condition  is,  according 
to  Brunswic,  much  more  common  than  one  should  think,  and  occurs  more 
often  after  gonorrhea  than  after  syphilis. 

Brunswic  has,  for  instance,  seen  a  young  man  of  nineteen  who  suffered 
from  a  rectal  stricture  after  having  had  several  attacks  of  gonorrheal  rectitis. 
He  subsequently  acquired  syphilis  (indurated  labial  chancre  with  typical 
submaxillary  adenitis,  roseola,  and  mucous  plaques),  which  illness  took  a 
normal  course.  There  can  be  no  doubt  that  in  this  case  the  rectal  stricture 
was  gonorrheal,  and  not  syphilitic. 

^  Brunswic-le-Bihan,  loc.  cit. 


THE  COMPLICATIONS  OF  GONORRHEA  235 

The  course  of  ano-rectal  gonorrhea  is  very  similar  to  that  of  a  gonorrheal 
urethritis — i.e.,  in  both  instances  the  ultimate  result  is  the  formation  of  a 
stricture.  The  gonorrheal  inflammation  produces  a  thickening  of  the  coats 
of  the  rectum,  which  form,  as  they  retract,  a  ring  or  a  cylinder  constricting 
the  lumen  of  the  terminal  gut. 

The  prognosis  should  be  a  guarded  one  in  cases  of  rectal  stricture.  As 
Hamonic  has  pointed  out,  they  soon  affect  the  general  health.  A  rebellious 
dyspepsia  supervenes,  ard  there  is  a  gradually  increasing  difficulty  in 
defecation.  Finally,  the  motions  lose  their  normal  character  completely. 
The  patient  suffers  from  a  persistent  diarrhea,  which  weakens  and  exhausts 
him. 

Proliferative  Rectitis.-^ — Ano-rectal  gonorrhea  assumes  sometimes  a 
proliferating  character.  Papillomatous  growths  form,  which  may  either 
be  sessile  or  pedunculated,  and  are  described  as  "  condylomata." 

Treatment. 

Gonorrheal  proctitis  should  be  treated  in  its  early  stage  with  irriga- 
tions consisting  of  boiled  water  or  a  weak  solution  of  permanganate.  If 
the  anal  sphincter  is  imphcated,  gauze  ribbon,  medicated  with  borax  or 
iodoform,  should  be  introduced  into  the  anus.  When  the  rectum  is  seriously 
affected,  the  best  treatment  is  local  therapy  carried  out  under  the  control 
of  the  rectoscope. 

Description  of  Luys's  Rectoscope. — This  instrument  consists  of  a  metal 
tube,  fitted  with  a  pilot,  which  is  18  centimetres  long,  and  has  an  internal 
diameter  of  2  centimetres.  This  is  the  usual  size,  but  longer  tubes,  30  centi- 
metres long,  have  been  made  at  my  request,  which  allow  one  to  examine 
the  whole  descending  colon.  The  lower  wall  of  the  tube  is  fitted  in  its 
entire  length  with  a  small  special  tube,  which  opens  about  0  5  centimetre 
within  the  distal  end  of  the  rectoscopic  tube.  The  other  extremity  of  the 
small  pipe  is  branched  and  fitted  with  two  taps.  One  of  the  latter  com- 
municates by  means  of  rubber  tubing  with  a  closed  vessel  in  which  a  vacuum 
is  made  by  means  of  a  filter  pump ;  the  other  tap  is  connected  with  bellows 
which  blow  air  into  the  rectum.  The  light  is  supplied  by  a  minute  cold 
lamp  mounted  on  a  long  holder  which  is  fixed  to  the  handle  of  the  recto- 
scope. This  portion  is  attached  to  the  tube  after  the  pilot  has  been  with- 
drawn. 

On  the  handle  is  a  movable  mounted  lens  which  has  a  focal  length 
corresponding  to  the  length  of  the  tube.  It  also  carries  an  electric  switch, 
and  receives  the  two  connecting  wires  from  the  battery  or  main.  Lastly, 
a  smaU  metal  ring  encirchng  a  window  is  supphed,  which  allows  one  to 

^  Luys,  "  La  Rectoscopy,"  Revue  de  Gynecol,  et  de  CJiir.  Abdom.,  June  6,  1910. 


236 


GONOREHEA 


obturate  hermetically  the  outer  end  of  the  rectoscopic  tube  when  one  desires 
to  inflate  the  rectum. 

One  sterihzes  the  rectoscopic  tube  and  its  pilot  by  boiling,  whilst  the 
lamps  and  their  holders  are  disinfected  by  formalin  vapours. 

Advantages. — The  chief  advantage  of  my  rectoscope  is  the  ease  and  the 
rapidity  with  which  it  enables  one  to  cleanse  the  rectal  mucous  membrane. 
With  other  instruments  a  tedious  and  revolting  preliminary  operation  is 
necessary  if  the  rectal  ampulla  contains  masses  of   feces.     This   scraping 


Fig.  129. — Luys's  Rectoscope. 


and  wiping  away  of  the  excreta  takes  up  a  considerable  amount  of  time, 
and  is  most  disagreeable.  It  can  be  avoided  by  using  my  instrument. 
One  has  only  to  let  some  hot  water  run  into  the  rectum  through  a  cannula 
which  one  passes  into  the  rectoscopic  tube.  In  this  way  the  rectal  cavity 
can  be  properly  cleaned,  and  any  excess  of  fluid,  and  with  it  any  impurities, 
are  aspirated  at  once  by  the  filter  pump.  The  rectum  is  thus  thoroughly 
cleansed  mechanically. 

Despite  the  rechning  position  in  which  the  patient  is  placed,  there  are 
cases  in  which  it  is  impossible  to  distend  the  rectum  sufficiently.     It  then 


THE  COMPLICATIONS  OF  GONORRHEA 


237 


becomes  necessary  to  inflate  the  organ  with  air.  The  second  tap  fitted 
on  the  instrument  is  opened,  and  air  enters  the  rectum  from  the  bellows. 
Its  pressure  is  maintained  by  closing  the  outer  end  of  the  rectoscopic  tube 
with  the  little  framed  window. 

Technique  of  Rectoscopy — Preparation  of  the  Patient. — It  is  advisable 
to  purge  the  patient  on  the  night  before  the  examination  takes  place.  This 
is,  however,  not  absolutely  necessary.  A  few  hours  before  the  investiga- 
tion an  enema  should  be  given,  or  else  the  patient  should  empty  his  bowels 
in  the  natural  way  before  being  examined.  The  bladder  should  be  emptied 
by  ordinary  micturition. 


^""^**---     //  \\#       / 

Pig.  130.— Rectoscope  in  Use:  Position  of  Patient  and  Surgeon. 


In  a  previous  visit  one  should  have  ascertained  by  digital  examination 
if  the  rectoscope  can  be  introduced  to  any  distance,  and  if  any  tight  stricture 
or  a  tumour  is  present. 

Local  Anesthesia. — It  is  well  in  the  case  of  sensitive  patients  to  anesthe- 
tize the  rectum  with  a  local  anesthetic  before  passing  the  tube.  This  is 
readily  done  by  introducing  a  small  mounted  swab  into  the  anus  which  has 
been  soaked  in  a  10  per  cent,  solution  of  stovain. 

Position  of  the  Patient. — The  pelvis  should  be  raised.  The  table  shown 
in  Fig.  130  is  very  convenient  for  rectoscopy.  Firm  supports  should  hold 
the  shoulders  and  prevent  the  patient  from  shpping  away  from  the  surgeon. 


238  GONORRHEA 

The  pelvis  should  just  touch  the  edge  of  the  table.  The  legs  should  be 
well  separated  and  supported  by  stirrups  or  holders. 

If  the  patient  is  thin,  a  highly  inchned  position  is  unnecessary.  As 
soon  as  he  is  put  on  the  slope,  the  abdominal  contents  fall  back  on  to  the 
diaphragm.  Air  enters  spontaneously  into  the  rectum  and  dilates  it. 
In  stout  people  the  conditions  are  very  different.  The  intra-abdominal 
plethora  prevents  the  rectal  cavity  from  expanding,  and  insufflation  is 
required. 

The  sloping  position  recommended  is  infinitely  better  than  the  knee- 
elbow  position  advocated  by  some  authorities.  The  latter  is  unpleasant 
and  very  tiring  for  the  patient,  and  there  is  something  revolting  about  it. 
Lastly,  a  good  inclined  plane  permits  one  to  graduate  the  entry  of  air  more 
readily  than  the  genu-pectoral  position. 

The  Introduction  of  the  Tube. — The  sterilized  tube  and  pilot  are  lubricated 
with  glycerine,  and  brought  into  contact  with  the  anus.  The  passing  of 
the  instrument  should  be  effected  with  great  gentleness  and  patience.  It 
is  well  for  the  patient  to  bear  down  in  order  to  relax  his  sphincter.  When 
no  obstacle  is  present,  such  as  a  stricture  or  a  tumour,  one  reaches  the  rectal 
ampulla  without  any  difficulty.  After  half  or  two-thirds  of  the  tube  has 
passed,  the  pilot  is  withdrawn. 

Lavage. — The  lower  tap  is  connected  with  the  filter  pump  by  means  of 
rubber  tubing,  and  one  inserts  between  the  rectoscopic  tube  and  the  pump 
a  vessel  which  allows  one  to  see  any  impurities  which  may  come  away  in 
the  washings.  One  then  makes  sure  that  everything  is  in  good  working 
order,  and  this  is  indicated  by  a  characteristic  whistling  sound  in  the  recto- 
scopic tube.  At  this  stage  the  other  (insufflation)  tap  should  be  completely 
closed.  One  now  runs  some  water  into  the  rectum  through  a  nozzle  which 
one  introduces  into  the  rectoscope.  The  washings,  which  are  immediately 
aspirated,  remove  all  impurities,  and  are  continued  until  they  come  out 
quite  clear. 

Illumination. — The  lamp  is  now  introduced  into  the  tube  of  the  recto- 
scope  and  the  handle  is  firmly  secured.  The  hght  is  switched  on,  and  the 
rectum  is  magnificently  illuminated.  Should  one  find  that  some  fecal 
matter  has  been  left  in  the  gut,  the  irrigation  is  repeated  until  the  mucosa 
is  perfectly  clean. 

By  proceeding  in  this  fashion  one  obtains  a  more  complete  and  more 
rapid  cleansing  than  by  swabbing  with  tampons- — a  tedious  and  unpleasant 
process.  This  cleaning  by  irrigation  is  of  special  value  when  the  mucous 
membrane  bleeds  readily.  Continuous  irrigation  carried  out  by  an  assistant 
is  very  useful  in  such  cases.  The  rectum  is  examined  under  water.  This 
method  gives  good  results,  and  is  preferable  to  all  others. 

Insufflation. — If  the  rectal  cavity  is  not  distended  sufficiently  after 


THE  COMPLICATIONS  OF  GONORRHEA  239 

the  patient  has  been  placed  in  the  sloping  position,  it  is  advisable  to  in- 
sufflate the  organ  with  air.  For  this  purpose  the  aspiration  tap  is  closed, 
and  the  other  one,  which  is  connected  with  the  bellows,  is  opened.  .  The 
outer  end  of  the  endoscopic  tube  having  been  shut  by  applying  the  mounted 
window,  an  assistant  works  the  bellows  until  the  rectum  is  sufficiently 
distended  and  can  be  examined  easily. 

The  aspiration  tap  must  be  closed  during  insufflation,  otherwise  the 
mucous  membrane  would  be  aspirated,  and  pain  and  hemorrhage  would 
follow. 

The  aspirator  should  never  he  working  when  the  outer  end  of  the  rectoscopic 
tube  is  closed  by  means  of  the  framed  window. 


Fig.  131. — Gonorrheal  Stricture  of  the  Eectum 

Value  of  Rectoscopy  in  Cases  of  Stricture  of  the  Rectum.— The  strictures 
of  the  rectum  are  usually  situated  low  down,  about  2  to  3  centimetres  from 
the  anus.  Hence  a  digital  examination  should  precede  rectoscopy  when- 
ever one  suspects  the  presence  of  a  stricture  of  the  lower  gut.  One  can 
thus  make  out  its  position,  and  introduce  the  tube  as  far  as  the  stricture. 
After  the  lavage  has  been  terminated,  the  whole  lower  circumference  and 
the  lumen  of  the  stricture  are  readily  examined.  This  procedure  gives 
valuable  information. 

It  is  well  known  that  the  proper  treatment  of  rectal  stricture  is  gradual 
and  methodical  dilatation.  As  a  rule,  this  treatment  is  carried  out  in  the 
dark  by  means  of  elastic  bougies  or  metal  dilators.  In  experienced  hands 
such  interventions  are  free  from  danger,  but  one  should  remember  that  they 


240  GONORRHEA 

have  been  followed  by  accidents,  and  that  they  are  not  free  from  danger. 
Perforation  of  the  rectum,  followed  by  peritonitis  and  death,  has  occurred 
on  many  occasions. 

Fig.  132,  which  is  drawn  from  Nature,  shows  a  case  in  which  the  lumen 
of  the  stricture  is  excentric  and  helicoidal,  instead  of  being  in  the  centre. 
Cases  of  this  kind  bring  home  the  danger  of  working  without  the  guidance 
of  the  rectoscope,  and  the  ease  with  which  ordinary  dilatation  treatment 
may  lead  to  perforation  of  the  gut  wall. 

Methodical  dilatation  under  the  control  of  the  rectoscope  is  thus  the 
best  and  safest  means  of  treating  strictures  of  the  rectum. 

In  fact,  it  is  extremely  easy  to  introduce  through  the  firmly-held  recto- 
scopic  tube  an  elastic  bougie  with  lead  interior,  and  this  instrument  will 


Fig.    132. — Excentric   Stricture   of   the   Rectum   due   to   Gonorrhea. 
Gradual  dilatation  under  the  control  of  the  rectoscope  avoids  all  danger. 

enter  the  stricture  by  its  own  weight  with  a  little  manipulation.  In  this 
fashion  the  narrowing  can  be  dilated  properly  and  without  any  risk.  "  False 
passages  "  and  disasters  are  inipossible  with  this  technique. 

There  are  some  other  advantages  connected  with  this  method.  Once 
a  sufficient  degree  of  dilatation  has  been  obtained  in  the  course  of  a  few 
visits,  the  rectoscopic  tube  and  its  pilot  are  often  available  as  dilators. 
Once  they  have  passed  the  upper  margin  of  the  stricture,  the  rectal  wall 
beyond  can  be  examined.  The  exact  length  of  the  narrowing  can  thus  be 
made  out,  and  one  can  ascertain  if  any  lesions  are  present  above  the  stricture. 
Local  treatment  can  be  apphed  with  advantage  to  any  portion  of  the  mucosa 


THE  COMPLICATIONS  OF  GONORRHEA  241 

which,  may  have  undergone  ulceration  or  some  other  change  on  account  of 
the  presence  of  the  stricture. 

Tincture  of  iodine  and  a  weak  solution  of  silver  nitrate  are  of  great 
service  in  these  cases,  and  when  necessary  direct  appUcations  with  the 
cautery  can  be  made — in  the  case  of  papillomata,  for  instance. 

AFFECTIONS  OF  THE  RESPIRATORY  ORGANS  OF  GONOCOCCAL  ORIGIN. 

Nasal  Gonorrhea. 

This  comphcation  is  very  rare,  exceptional  even,  although  the  pituitary 
mucous  membrane  is  exposed  to  gonococcal  infection,  as  it  is  so  close  to 
the  eye.  Andrew  Duncan  met  with  a  case  in  which  a  young  man  developed 
nasal  gonorrhea  after  having  wiped  his  nose  on  a  towel  which  was  soiled 
with  pus  from  his  urethra.  A  special  type  of  coryza  supervened,  which 
the  author  considered  to  be  gonorrheal. 

Several  other  observations  plead  in  favour  of  the  existence  of  nasal 
gonorrhea,  but  the  experimental  researches  which  some  observers  have 
undertaken  have  not  confirmed  these  chnical  findings. 

Diday  tried  on  eight  or  ten  occasions  to  produce  a  nasal  gonorrhea  by 
rubbing  the  septum  with  a  finger  which  had  been  soiled  with  gonorrheal  pus. 

Bonniere  also  failed  in  his  attempt  to  produce  a  gonococcal  infection 
of  the  nose  by  painting  the  pituitary  mucous  membrane  with  a  brush  which 
had  been  dipped  into  pus  derived  from  a  case  of  gonorrheal  ophthalmia. 

However,  the  coryza  of  the  new-born  deserves  attention,  and  it  would 
seem,  if  we  may  believe  Jullien,  that  a  number  of  cases  of  coryza  supervening 
on  the  second  or  third  day  after  birth  are  of  gonococcal  origin,  and  that  they 
are  contracted  by  the  infants  at  birth  from  the  gonorrheal  infection  present 
in  the  generative  organs  of  their  mothers. 

Gonorrheal  Pleurisy. 

•  Gonorrheal  pleurisy  has  escaped  notice  for  a  long  time,  and  the  mere 
coincidence  of  gonorrhea  and  of  pleurisy  is  not  suflB.cient  to  establish  a 
causal  relation  between  them.  The  few  observations  which  were  published 
before  1894  deserve,  therefore,  no  credit,  as  the  diagnosis  was  never  certain 
and  never  based  upon  a  proper  bacteriological  examination. 

However,  Guiard^  relates  two  cases,  one  belonging  to  Chiaso  and 
Fournier  (1894),  and  another  one  due  to  Mazza,  in  which  little  girls  of  ten 
and  eleven  respectively  had  been  raped,  and  were  subsequently  affected 
with  pleurisy.  The  fluid  aspirated  from  the  chest  contained  in  each  cate 
gonococci. 

^  Guiard,  Les  Ccmplications  de  la  Blennorragit,  Paris,  1898,  p.  391. 

16 


242  GONOREHEA 

Felix  Bertrand^  has  publistied  the  case  of  a  woman  who  on  the  seventh 
day  of  her  gonorrheal  vaginitis  developed  a  pleurisy  with  effusion.  Ex- 
amination of  the  fluid  revealed  the  presence  of  gonococcus,  according  to 
the  author. 

In  all  cases  noted  and  described  the  amount  of  exudate  is  moderate. 
The  pleurisy  is  usually  unilateral,  and  shifts  in  a  remarkable  manner.  The 
effusion  comes  on  in  a  few  hours,  and  tends  to  disappear  with  equal 
rapidity. 

Geraud  of  Nice^  has  published  an  interesting  case  of  gonorrheal  pleurisy 
in  a  young  man  of  nineteen  who  had  a  profuse  urethral  discharge.  The 
bacteriological  examination  of  the  pus  withdrawn  by  aspiratory  puncture 
from  the  chest  gave  a  pure  culture  of  the  gonococcus.  Thoracentesis  was 
deemed  necessary,  and  led  to  a  complete  cure.  This  is  the  first  case  of 
purulent  gonococcal  pleurisy  which  has  been  cured  by  a  surgical  interven- 
tion. 

OCULAR  COMPLICATIONS  OF  GONORRHEA. 

By  Dr.  Pj^chin.^ 

Infection  of  the  eye  by  the  gonococcus  is  brought  about  in  three  ways: 

1.  By  direct  spreading  from  a  focus  in  the  neighbourhood.  The  in- 
fection of  the  eye  is  then  a  local  complication.  These  cases  may  be  dis- 
regarded here. 

2.  By  exogenous  infection. 

3.  By  endogenous  infection,  metastasis,  gonococcemia. 

1.  Exogenous  Infection — Exogenous  Gonococcal  Conjunctivitis. 

1.  Gonococcal  Conjunctivitis  in  the  New-Born. — This  affection  is  very 
common  in  infants  whose  mothers  are  suffering  from  gonorrheal  vaginitis. 
The  contamination  usually  takes  place  at  birth,  whilst  the  head  of  the  infant 
passes  through  the  vagina.  Some  of  the  secretion  of  the  latter  organ  is 
carried  along  on  the  eyelids,  and  subsequently  the  infectious  material  finds 
its  way  through  the  palpebral  fissure  into  the  eye. 

The  inflammation  of  the  conjunctiva  supervenes  on  the  second  or  third 
diy  after  birth.  An  incubation  period  of  four  or  five  days  is  very  rare, 
and  an  interval  of  six  or  seven  diys  is  quite  exceptional.  A  conjunctivitis 
which  makes  its  appearance  after  four  or  five  days  should  not  be  brought 

1  Bertrand,  Arch.  Gin.  de  Med.,  October,  1895,  p.  404;  and  These  sur  la  Pleuresie 
Blennorragique,  Paris,  1896. 

2  Bull,  et  MCm.  de  la  Soc.  de  Med.  et  de  Climntol.  de  Nice,  1912,  No.  3. 

3  Dr.  Pecliin,  who  is  a  well-known  authority  on  this  subject,  has  very  kindly  con- 
sented to  write  this  paragraph  on  gonorrheal  affections  of  the  eye,  and  we  wish  to  make 
this  an  opportunity  for  tendering  him  our  best  thanks. 


THE  COMPLICATIONS  OF  GONOERHEA  2i3 

into  connection  with  the  birth.  The  contamination  has  occurred  later 
either  through  soiled  linen  (mother  and  baby  using  the  same  towel),  or 
insufficient  antiseptic  precautions  when  mother  and  baby  are  washed,  or 
through  another  infant  (maternity  hospitals,  children's  homes,  etc.).  When 
the  conjunctivitis  is  congenital,  the  infection  has  taken  place  ante  fartum, 
in  utero;  the  membranes  ruptured  prematurely,  and  the  gonorrheal  secretions 
of  the  mother's  vagina  found  their  way  into  the  amniotic  sac. 

The  infection  of  the  conjunctiva  is  characterized  by  a  more  or  less  free 
amount  of  discharge  and  a  variable  degree  of  swelling  of  the  eyehds. 
Intense  suppuration  is  very  common,  but  there  are  benign  forms  with  slight 
symptoms  in  which  the  infection  is  attenuated.  Occasionally  one  meets 
with  fulminating  attacks,  but  they  are  not  common.  The  symptoms  are 
usually  severe,  and  the  disease  takes  a  rapid  and  destructive  course.  Per- 
foration, and  even  panophthalmia,  supervene  and  defy  all  therapy. 

The  duration  of  conjunctivitis  varies  roughly  from  three  weeks  to  two 
months,  if  no  complications  arise. 

The  most  frequent  complication  of  gonococcal  conjunctivitis  is  an  in- 
fection of  the  cornea  which  may  lead  to  ulceration,  perforation,  retro- 
choroidal  hemorrhage,  lesions  of  the  iris,  secondary  glaucoma,  leucoma, 
staphyloma,  panophthalmia,  and  anterior  polar  cataract. 

Vulvo- vaginitis  contracted  in  the  same  way  as  this  type  of  conjunctivitis 
may  in  its  turn  lead  to  conjunctivitis. 

Gonococcal  conjunctivitis  is  the  most  serious  form  of  conjunctivitis  met 
with  in  infants.  The  chances  of  a  complete  cure  without  any  corneal  lesions 
depends  on  the  promptness  of  the  treatment. 

For  further  details  on  the  symptoms  and  on  the  treatment  the  reader 
should  consult  the  textbooks  on  diseases  of  the  eye. 

The  best  prophylactic  measure  against  ophthalmia  neonatorum  consists 
in  putting  a  few  drops  of  a  silver  nitrate  solution  into  the  conjunctival  sac 
immediately  after  birth.  One  tends  more  and  more,  however,  to  replace 
the  nitrate  by  organic  silver  salts,  such  as  argyrol  or  sophol,  which  has 
been  so  warmly  advocated  by  Von  Herff . 

2.  Gonococcal  Conjunctivitis  in  Children  and  in  Adults. — Broadly 
speaking,  gonococcal  conjunctivitis  takes  a  similar  course  in  children  and  in 
adults  to  that  met  with  in  infants. 

The  prognosis  is  more  serious,  as  complications  involving  the  cornea  are 
more  common. 

Most  cases  of  vulvitis  in  little  girls  are  due  to  gonorrhea,  and  vulvo- 
vaginitis is  a  frequent  cause  of  gonorrheal  conjunctivitis.  Hence  this  con- 
dition should  be  sought  for  and  should  be  treated.  This  fact  should  also 
be  borne  in  mind  from  a  prophylactic  point  of  view. 


2M  GONOEKHEA 

2.  Endogenous  Infection. 

Whilst  the  exogenous  variety  of  conjunctivitis  is  well  known,  the 
endogenous  gonococcal  infections  of  the  eye  have  been  but  little  studied. 
They  deserve  to  be  called  metastatic,  but  this  term  is  usually  reserved  for 
those  endogenous  infections  which  implicate  all  the  coats  of  the  eyeball. 

Endogenous  metastatic  infection  due  to  gonorrhea  may  involve  the 
conjunctiva,  the  uveal  tract,  the  sensory  apparatus  of  the  eye,  and  Tenon's 
capsule,  and  it  may  lead  to  thrombosis  of  the  central  vein  of  the  retina, 
and  to  dacryo-adenitis. 

That  these  metastases  should  occur  is  not  surprising,  considering  the 
vast  number  of  other  systemic  complications  of  generalized  gonorrhea. 

1.  Conjunctivitis  through  Endogenous  Infection— Spontaneous  Meta- 
static Gonococcal  Conjunctivitis— Sero- Vascular  Conjunctivitis.^ — This 
gonococcal  conjunctivitis,  which  is  really  an  inflammation  of  the  con- 
junctival epibulbar  connective  tissue  (mucosa,  submucosa,  and  episcle- 
rotic),  is  only  found  in  patients  who  are  suffering  from  gonorrhea.  It  thus 
differs  from  the  form  of  conjunctivitis  described  above,  which  may  occur 
in  any  healthy  person,  and  is  the  result  of  a  direct  local  contamination. 
Apart  from  this  etiological  difEerence,  the  chnical  behaviour  of  the  two 
kinds  of  conjunctivitis  is  very  dissimilar.  The  exogenous  type  is  serious; 
there  is  intense  inflammation  and  a  profuse  discharge,  so  much  so  that  it 
may  be  considered  to  be  the  paradigm  of  purulent  conjunctivitis.  The 
phenomena  of  reaction  are  marked  (pain,  photophobia,  blepharospasm, 
etc.),  and  there  is  the  great  danger  of  the  cornea  being  implicated.  The 
metastatic  form  is  mild  in  its  symptoms,  and  the  prognosis  is  a  good  one. 

The  eye  is  more  or  less  red  and  hyperemic.  The  bulbar  conjunctiva 
IS  shghtly  raised  by  a  serous  chemosis,  but  there  is  no  discharge.  The  eye 
is  not  closed,  there  is  no  photophobia,  and  there  is  no  pain.  This  condition 
lasts  about  ten  to  twenty  days,  and  then  disappears  without  leaving  a  trace. 
The  vision  remains  perfect,  and  the  cornea  is  never  affected  to  any  extent. 
At  the  most,  a  few  phlyctenules  may  be  found. 

This  conjunctivitis  owes  its  origin  to  a  generalized  gonococcal  infection, 
in  the  same  way  as  gonorrheal  rheumatism,  for  instance.  It  very  often 
ushers  in  this  latter  complication,  or  it  may  accompany  it,  or  it  may  follow 
immediately  upon  it. 

It  has  the  same  shifting  character  as  certain  gonorrheal  articular  affec- 
tions.    It  passes  from  one  eye  to  the  other,  disappears,  and  recurs. 

As  a  rule,  the  bacteriological  findings  have  been  negative  in  these  cases. 
The  gonococci  have  only  been  traced  exceptionally  in  the  conjunctiva,  and 
then  they  were  associated,  just  as  in  the  case  of  joint  lesions,  with  staphylo- 

^  Vide  Nouvelle  Pratique  Medico-Chirurgicale  Illusiree,  vol.  i.,  p.  1022. 


THE  COMPLICATIONS  OF  GONOKRHEA  245 

cocci.  One  can  therefore  say  that  the  gonococcal  infection  prepared  the 
way  for  the  staphylococci,  which  subsequently  set  up  the  conjunctivitis. 
The  gonococcal  toxin  may  also  be  incriminated,  when  no  gonococci  are 
found.     But  this  is  hypothetical. 

The  prognosis  is  favourable  providing  the  inflammation  remains  hmited 
to  the  conjunctiva. 

2.  Gonococcal  Infection  of  the  Uveal  Tract— Iritis— Choroiditis.— 
Endogenous  gonococcal  infection  is  hable  to  affect  the  uveal  tract,  either 
secondarily  or  by  developing  a  true  gonococcal  metastasis. 

The  iris  may  be  imphcated  alone  (plastic  iritis,  or  purulent  iritis  with 
hypopyon,  or  hemorrhagic  iritis),  or  so-called  "  serous  iritis  "  may  be  present, 
in  which  case  the  whole  uveal  tract  is  involved. 

Metastatic  choroiditis  has  been  often  observed  in  cases  of  systemic 
infections.  Primary  lesions  in  the  various  regions  may  ultimately  lead 
to  this  complication  after  the  infection  has  become  general. 

It  is  generally  not  well  known  that  gonococcemia  gives  rise  to  a  meta- 
static choroiditis,  and  we  wish  to  draw  attention  to  this  ocular  complication 
of  gonorrhea,  especially  as  it  occasionally  supervenes  at  a  very  remote 
period.  We  have  seen  it  to  come  on  two,  three,  and  even  twenty-five  years 
after  the  original  infection.  The  metastatic  choroiditis  assumed  a  different 
course  in  these  various  cases,  but  it  was  always  caused  by  a  gonococcal 
infection  of  the  genito-urinary  organs  which  had  not  been  cured,  and  which 
had  remained  latent  for  years.  As  the  usual  signs  of  chronic  gonorrhea 
are  absent,  a  methodical  exploration  of  the  genito-urinary  organs  is  the 
only  available  means  of  tracing  the  true  origin  of  this  ocular  affection. 

The  reader  should  consult  one  of  the  ordinary  textbooks  for  a  general 
description  of  metastatic  choroiditis.  The  chnical  aspect  and  the  evolution 
of  the  malady  vary  with  the  nature  of  the  infection  and  according  to  the 
part  of  the  eye  which  is  most  affected. 

The  gonococci  reach  the  eye  through  the  blood-stream.  In  the  case 
of  the  retina,  they  are  conveyed  by  the  arteria  centralis  retinae ;  the  uvea 
is  reached  through  the  long  cihary  vessels.  They  travel  to  the  iris  through 
the  anterior  cihary  arteries,  and  to  the  choroid  through  the  short  posterior 
cihary  vessels. 

A  case  which  I  saw  together  with  Dr.  Luys  presented  the  following 
features : 

A  young  man  contracted  an  attack  of  gonorrhea  in  June,  1908,  whicli  took  a  serious 
course,  and  was  followed  within  a  month  by  a  severe  gonococcal  irido -choroiditis,  which 
led  to  the  loss  of  the  left  eye.  Despite  this  disaster,  the  patient  did  not  think  it  fit 
to  seek  treatment.  Four  years  later  he  consulted  Dr.  Pechin,  who  suspected  that  a 
general  infection  might  have  been  the  cause  of  the  loss  of  the  left  eye.  He  persuaded 
the  patient  to  have  his  urine  examined.     This  was  done,  and  M.  Leclerc  was  able  to 


246  GONOKKHEA 

demonstrate  the  presence  of  Neisser's  organism  in  the  deposit.  The  patient  was  thus 
still  suffering  from  gonorrhea,  and  it  was  highly  imperative  that  he  should  be  cured 
in  order  to  safeguard  him  against  further  sequelae  of  this  prolonged  infection,  such  as 
a  metastatic  infection  of  the  remaining  healthy  eye.  Dr.  Pechin  therefore  sent  him  to 
Luys  in  November,  1912. 

At  this  time  the  patient  had  no  discharge,  his  urine  was  practically  clear,  and  con- 
tained but  a  few  filaments.  The  examination  of  the  urethra  with  an  exploratory 
bougie  No.  24  showed  no  stricture,  but  the  verumontanum  was  abnormally  sensitive, 
and  bled  considerably  as  the  olive  passed  over  it.  After  a  few  dilatations  with  curved 
metal  sounds  the  urethra  was  endoscoped.  The  prostatic  fossette  was  quite  healthy, 
and  there  were  no  lesions  in  the  penile  urethra.  However,  the  bolster  over  the  veru- 
montanum was  swollen  and  badly  folded.  The  verumontanum  itself  was  enlarged, 
bled  as  soon  as  it  was  touched,  and  resembled  a  raspberry.  It  was  in  a  state  of  chronic 
inflammation. 

This  naturally  rendered  an  examination  of  the  seminal  vesicles  imperative,  as  they 
were  most  likely  to  be  the  starting-point  of  this  inflammation.  On  massage,  the  pros- 
tate was  found  to  be  absolutely  healthy,  but  the  seminal  vesicles  were  very  painful  and 
yielded  well-marked  casts.  The  presence  of  a  chronic  inflammation  of  the  seminal 
vesicles  was  thus  ascertained. 

Regular  massage  of  the  vesicles  and  dilatation  of  the  prostatic  urethra  by  means 
of  Frank's  instrument  were  resorted  to,  and  later  on  topics  were  applied  to  the  veru- 
montanum under  the  control  of  the  urethroscope. 

This  treatment  had  the  happiest  effect.  The  seminal  vesicles  became  less  and  less 
painful  when  massaged,  and  yielded  less  and  less  debris.  The  verumontanum  ceased 
to  bleed,  although  it  was  difformed. 

Towards  the  end  of  January,  1913,  the  urine  was  again  centrifuged,  and  sent  to 
M.  Leclerc  for  a  bacteriological  examination.  Neither  the  gonococcus  nor  any  other 
pathogenic  cocci  were  found. 

In  order  to  make  quite  sure  that  the  gonococci  had  completely  disappeared,  the 
seminal  vesicles  were  carefully  massaged,  and  the  secretion  was  collected  in  a  glass. 
M.  Leclerc  again  made  the  examination,  and  found  a  number  of  spermatozoa,  but, 
despite  all  efforts,  he  was  unable  to  discover  any  gonococci. 

There  is  thus  httle  doubt  that  the  patient  in  question  harboured  Neisser's 
organism  for  four  years  or  so,  and  that  the  focus  which  sheltered  them,  was 
in  the  seminal  vesicles. 

3.  Optic  Neuritis. — Metatastic  optic  neuritis  belongs  to  the  same  type  as 
the  gonococcal  polyneurites  and  the  cerebro- spinal  lesions.  In  the  same 
way  as  the  gonorrheal  infection  reaches  the  chord  through  the  arteries  or 
veins,  the  optic  nerve  is  affected  through  the  blood-stream.  This  optic 
neuritis  is  an  infective  neuritis,  and  the  chord,  or  even  the  brain,  may  be 
involved. 

Other  gonococcal  lesions  of  the  eye  which  deserve  to  be  mentioned  are — ■ 

Tenonitis  (inflammation  of  Tenon's  capsule). 
Thromhofhlebitis  of  the  central  vein  of  the  retina. 
Dacryo-adenitis . 

Treatment. — The  local  therapy  of  the  ophthalmic  lesions  of  gonorrhea 
need  not  be  mentioned  here,  as  it  is  described  in  the  textbooks  which  deal 
with  the  diseases  of  the  eye. 


THE  COMPLICATIONS  OF  GONOREHEA  247 

When  the  infection  is  exogenous,  local  treatment  is  of  the  utmost  value ; 
but  in  endogenous  cases  it  is  often  powerless. 

Hence  it  is  imperative  to  treat  the  primary  focus  from  the  beginning. 
To  cure  the  lesions  present  in  the  genito- urinary  organs  is  the  best  prophy- 
lactic measure  against  ocular  complications.  If  carried  out  properly  and 
at  once,  there  is  every  chance  of  localizing  the  infection  and  of  preventing 
complications.  When  endogenous  ocular  lesions  have  supervened,  it  still 
remains  essential.  By  treating  and  curing  the  primary  focus  in  the  sexual 
organs,  one  does  away  with  an  unsuspected  source  of  generalized  infection, 
especially  in  the  cases  which  develop  complications  at  a  late  date. 

NERVOUS  COMPLICATIONS  OF  GONORRHEA. 

It  is  perfectly  feasible  that  the  nervous  system  should  be  implicated 
when  a  gonorrheal  infection  becomes  general  and  affects  the  whole  body. 
Cases  of  meningitis,  neuritis,  and  myelitis,  have  been  recorded. 

Gonococcal  Meningitis. 

An  instance  of  gonococcal  meningitis  has  been  pubhshed  by  D.  Bieck.^ 
A  man  of  forty-eight  who  had  been  suffering  from  a  chronic  discharge  for 
a  year,  developed  a  fresh  discharge.  After  six  days  he  became  deUrious 
and  maniacal,  and  coma  and  death  followed  shortly  afterwards.  At  the 
autopsy  exudative  patches  were  found  on  the  cerebral  pia  mater,  especially 
in  the  regions  of  the  right  frontal  and  parietal  lobes.  The  microscopic 
examination  of  these  exudates  revealed  the  presence  of  the  gonococcus. 

Neuralgiae  of  Gonorrheal  Origin. 

Of  all  forms  of  neuralgia  met  with  in  gonorrhea,  gonorrheal  sciatica  is 
the  most  important.  Professor  Fournier  has  studied  it  carefully  and  demon- 
strated its  gonococcal  nature.  Its  onset  occurs  usually  during  the  second 
or  third  month  of  the  gonococcal  invasion.  It  is  sudden,  lasts  three  to 
four  days  as  a  rule,  and  is  very  seldom  present  for  more  than  fifteen  to 
twenty  days.  It  is  most  amenable  to  treatment,  and  often  vanishes  as 
soon  as  one  manages  to  subdue  the  discharge. 

Crural  neuralgiw  and  peripheral  polyneuritis  are  also  met  with  as  com- 
plications of  gonorrhea. 

Gonorrheal  Myelitis. 

Hay  em  and  Parmentier  in  1888  were  the  first  to  draw  attention  to 
the  meningo- medullary  complications  of  gonorrhea.  In  the  following 
year  Dufour  (1889)  gave  a  complete  resume  of  the  subject  in  his  thesis. 

^  Bieck,  Wratschebnaja  Gazeta,  1907,  No.  46. 


248  GONORRHEA 

In  1894  Barie  also  published  a  thesis  on  this  subject. 

The  meningo- medullary  comphcations  of  gonorrhea  are  rare.  They 
usually  supervene  about  the  third  or  fourth  week  of  the  disease. 

More  or  less  severe  pain  in  the  lumbar  region,  accompanied  by  girdle 
pains,  is  noted.  But  the  most  characteristic  symptom  is  a  paraplegia, 
which  usually  comes  on  gradually,  but  occasionally  it  is  complete  at  its 
onset. 

Sphincter  troubles  are  also  met  with:  retention  of  urine  and  constipation; 
or  the  reverse,  incontinence  of  urine  and  feces. 

Clonic  and  choreic  movements  and  localized  contractions  have  also  been 
observed. 

The  knee-jerks  are  usually  exaggerated,  but  they  may  be  diminished 
or  absent.     Ankle-clonus  is  also  sometimes  present. 

Muscular  atrophy  has  been  noted  repeatedly,  and  when  present  to  a 
marked  degree  it  is  of  serous  import.  A  median  eschar  over  the  sacrum 
is  also  a  very  bad  sign. 

All  these  disturbances  appear  to  be,  in  a  certain  number  of  the  cases 
pubHshed,  really  due  to  the  action  of  the  gonococcus  or  of  its  toxin  upon 
the  meninges  and  the  chord. 

Marcel  Labbe^  has  pubHshed  the  case  of  a  man  of  thirty-five  who  had 
never  had  syphihs,  and  who  developed  joint  lesions  in  his  legs  after  gonor- 
rhea. He  became  the  prey  of  great  muscular  weakness,  and  was  unable 
to  stand;  his  lower  Hmbs  doubled  up  under  him,  and  he  experienced  ful- 
minating pains  in  his  thighs  and  legs.  For  a  few  days  he  found  it  difficult 
to  pass  water,  but  he  never  suffered  from  incontinence  of  urine  or  feces. 
The  muscular  atrophy  was  well  marked  about  the  leg  and  the  thigh;  the 
reflexes  of  patella  and  of  the  tendo  Achilhs  were  exaggerated  and  produced 
some  epileptiform  tremor. 

In  November,  1910,  I  observed  signs  of  medullary  irritation  in  a  patient 
of  Dr.  Drugman  of  Monte  Carlo.  The  youth  in  point  was  suffering  from  a 
gonorrheal  vesiculitis,  and  was  being  regularly  treated  with  urethro- vesical 
irrigations  for  his  gonorrheal  discharge,  when  he  suddenly  developed  acute 
retention.  There  was  no  mechanical  obstruction,  and  rectal  palpation 
failed  to  show  anything  abnormal  in  the  prostate  and  in  Cowper's  glands. 

The  left  seminal  vesicle  was  slightly  affected.  It  was  not  much  swollen, 
but  there  were  a  few  adherent  nodules  in  it.  The  urethra  was  perfectly 
free,  there  was  no  trace  of  any  stricture,  and  the  urine  was  quite  clear. 

During  eight  to  ten  consecutive  days  he  suffered  from  complete  retention, 
which  gave  rise  to  intense  pain,  and  had  to  be  reheved  by  the  passing  of 
a  soft  rubber  catheter. 

As  no  local  trouble  was  found  which  could  be  made  responsible  for  the 

1  Journal  des  Praticiens,  July  26,  1901. 


THE  COMPLICATIONS  OF  GONORKHEA  249 

retention,  a  nervous  cause  had  to  be  considered,  especially  as  the  patient 
displayed  signs  of  spinal  irritation.  His  pupils  were  widely  dilated,  his 
patellar  reflexes  were  much  exaggerated,  and  ankle-clonus  was  also  present. 

Under  rest  in  bed,  regular  passing  of  a  catheter  combined  with  urethro- 
vesical  irrigation  and  massage  of  the  seminal  vesicle,  the  trouble  cleared 
up,  and  the  patient  was  completely  cured. 

The  paraplegiae  are  generally  spastic,  and  accompanied  by  shght  sphincter 
troubles  and  considerable  muscular  atrophy.  They  usually  coincide  with 
a  mild  attack  of  rheumatism,  and  are  shght  and  curable,  as  a  rule. 

It  seems  probable  that  the  gonococcal  toxins  alter  the  cells  of  the  spinal 
cord,  and  produce  foci  of  myelitis,  traces  of  which  have  been  found  post 
mortem  in  a  few  instances. 

The  prognosis  of  gonorrheal  paraplegia  is  favourable.  Recovery  takes 
place,  as  a  rule,  within  a  few  months  or  a  year.  Sulphur  baths,  massage, 
and  electric  treatment  of  the  muscles  are  of  great  value. 

The  therapy  of  meningo- myelitis  should  consist  firstly  in  the  removal 
of  the  main  focus  of  the  gonorrheal  infection — i.e.,  treatment  of  the  urethra 
and  its  appendages — and  secondly  in  appropriate  symptomatic  treatment 
of  the  various  manifestations  of  the  myelitis. 


CEREBRAL  COMPLICATIONS  OF  GONORRHEA. 

The  cerebral  complications  of  gonorrhea  are  more  obscure  than  those 
of  the  spinal  cord. 

Gonorrheal  delirium  has  been  described  by  Bourdon  (1868),  Bonnet 
(1877),  insanity  on  a  gonorrheal  basis  by  Vidar  (1875)  in  his  thesis,  and 
apoplexy  by  the  same  author.  But  the  evidence  produced  is  not  absolutely 
conclusive.  ■•• 

^  See  on  this  matter  the  curious  book  by  Professor  Silvio  Venturi,  Correlations 
Psycho-Sexudles,  Lyon  (Storck),  1899,  especially  p.  305  (A.  F.). 


CHAPTER  X 
GONORRHEA  IN  WOMEN  AND  CHILDREN 

GONORRHEA  IN  WOMEN. 

Gonorrhea  in  the  female  is  a  serious  illness  owing  to  its  exasperating 
tenacity,  and  also  owing  to  the  formidable  complications  which  frequently 
supervene.  Amongst  -the  latter  metritis  and  salpingitis  are  by  no  means 
uncommon,  and  usually  require  in  the  end  serious  operations  which  mutilate 
the  patient  and  render  her  sterile. 

In  women  gonorrhea  takes  an  essentially  chronic  course,  and  it  is  common 
to  j&nd  the  gonococcus  remaining  active  in  them  for  a  considerable  number 
of  years.  Moreover,  to  make  matters  worse,  most  women  are  not  aware 
that  they  are  suffering  from  gonorrhea,  and  have  not  the  faintest  suspicion 
that  they  are  contagious.  This  statement  is  especially  true  in  the  case  of 
young  wives  who  have  been  infected  by  their  husbands  shortly  after  their 
marriage.  This  "  gonorrhea  of  the  innocent,"  as  Verchere  calls  it,  is  by 
no  means  rare,  as  many  a  man  suffering  from  gleet  contracts  a  union  without 
taking  the  trouble  of  seeing  that  he  is  cured,  be  it  that  the  marriage  is  of 
financial  advantage  to  him  or  that  he  is  merely  careless  or  ignorant. 

Once  infected,  the  women  pay  little  attention  to  their  illness  as  a  rule, 
with  the  result  that  the  lesions  become  more  and  more  pronounced  and  very 
difficult  to  cure. 

"  All  women  are  exposed  to  gonorrhea;  it  has  no  respect  for  social  position 
and  virtue,"  says  Verchere,  one  of  the  greatest  authorities  on  gonorrhea 
in  women.  ^ 

Fournier's  statistics  show  that  this  disease  is  far  more  common  amongst 
kept  women,  actresses  (138  out  of  387),  and  working  girls^  (126  out  of  387), 
than  amongst  the  regular  prostitutes  (12  out  of  287).  This  discrepancy 
is  no  doubt  due  to  the  exquisite  knowledge  of  venereal  diseases  which  many 
prostitutes  can  boast  of.  "  They  understand  how  to  examine  the  man 
who  is  about  to  obtain  their  favours"  (Verchere);  they  douche  properly 
after  each  coitus,  and  resort  to  a  series  of  other  precautions  which  safeguard 
them. 

^  Verchere,  La  Blennorragie  chez  la  Femme,  Paris  (Rueff),  1894. 
2  Factory  girls,  servant  girls,  etc. 

250 


GONORRHEA  IN  WOMEN  AND  CHILDREN  251 

The  structure  of  the  female  generative  organs,  with  its  numerous  folds 
about  the  vulva,  the  urethra,  the  vagina,  and  the  uterus,  ofEers  admirable 
hiding-places  for  the  gonococci,  in  which  they  thrive  and  are  able  to  resist 
even  the  most  carefully  planned  and  best-conducted  therapeutic  efforts. 

It  is  unquestionable  that  the  overwhelming  majority  of  women  are 
infected  through  sexual  intercourse. 

But  there  are  also  other  causes,  as  has  already  been  pointed  out  in 
Chapter  III.  (p.  21).  Inert  objects,  for  instance,  which  are  soiled  with 
matter  containing  gonococci  (towels,  thermometers,  nozzles,  sponges,  etc.) 
may  bring  about  the  contamination,  and  the  cases  are  by  no  means  rare 
in  which  ladies  have  been  infected  through  their  own  toilet  articles  after 
they  had  been  used  during  their  absence  by  their  diseased  maids. 

An  instance  in  point  which  came  under  my  personal  observation  is  the 
following: 

A  married  man,  who  had  had  relations  with  a  young  woman  of  twenty-four  for  a 
considerable  time,  noticed  one  day  a  discharge  which  seemed  to  him  inexplicable. 
My  "  mistress  has  nothing;  it  must  be  herpes,"  he  said  when  he  consulted  me.  I  was 
unable  to  find  any  gonococci  in  his  discharge,  and  diagnosed  an  aseptic  urethritis. 
Asked  if  I  thought  that  his  mistress  had  any  disease  about  her  genitals,  I  replied  in 
the  affirmative.  He  therefore  sent  me  his  young  lady,  although  he  did  not  believe 
me,  and  I  examined  her.  She  was  suffering  from  a  typical  cervicitis.  The  cervix  was 
swollen,  hyperemic,  and  gave  issue  to  a  considerable  amount  of  discharge,  consisting 
of  pus  and  blood.  After  a  long  cross-examination,  she  finally  admitted  that  her  dis- 
charge had  come  on  after  the  use  of  an  old  and  dirty  instrument  for  a  certain  purpose. 

The  infection  of  the  young  woman  and  of  her  lover  was  thus  explained. 

The  acute  stage  of  gonorrhea  is  nearly  always  very  short  in  women, 
and  often  escapes  notice.  Its  intensity  is  most  variable.  There  may  be 
some  slight  itching  about  the  Aoilva  and  the  labia  minora,  or  a  burning 
sensation  in  the  urethra  during  micturition. 

On  inspection  the  mucous  membrane  of  the  vulva  is  found  to  be  con- 
gested, red,  shiny,  and  sometimes  edematous  and  covered  with  ulcerations. 
A  whitish  discharge  which  soils  and  stiffens  the  linen  is  present. 
The  urinary  meatus  is  red,  puffy,  and  a  bead  of  pus  containing  gonococci 
escapes  from  it  either  spontaneously  or  on  making  pressure  on  the  urethra. 
The  inflammation  of  the  vagina  is  often  intense,  and  renders  all  examinations 
impossible.  Vaginismus  is  common  and  prevents  sexual  intercourse. 
There  is  so  much  pain  that  the  vulvar  orifice  and  the  levator  ani  contract. 
The  cervix  is  usually  enlarged,  congested,  and  ulcerated.  A  more  or  less 
free,  and  sometimes  blood-stained,  discharge  is  seen  to  escape  from  its  os. 

Bartholin's  glands  are  frequently  involved.  Sometimes  the  pus  is 
pent  up  in  them,  and  an  acute  suppurative  bartholinitis  supervenes.  In 
other  instances  the  matter  can  be  squeezed  out  of  the  gland  by  making 
pressure  on  the  latter. 


252  GONORRHEA 

Gonorrhea  takes  a  very  slow  course  in  women.  The  symptoms  men- 
tioned are  often  extremely  mild,  especially  if  the  patient  is  very  clean  in  her 
habits.  The  disease  may  then  escape  notice  for  some  time,  and  only  be 
recognized  after  serious  and  rebellious  lesions  have  developed. 

The  gonococcus  is  capable  of  remaining  dormant  for  many  months,  but 
once  the  conditions  become  favourable,  it  resumes  its  activity.  This  fact 
explains,  for  instance,  the  infections  at  long  intervals  which  follow  upon 
a  marked  orgasm  and  luxurious  feeding,  or  occur  just  before  or  after 
menstruation. 

Amongst  the  most  common  local  complications,  chronic  urethritis, 
urethral  stricture,  chronic  metritis,  and  salpingitis,  deserve  a  special  mention. 
It  need  hardly  be  stated  that  women  who  are  suffering  from  gonorrhea 
are  exposed  to  the  same  systemic  comphcations  as  men:  gonorrheal  rheu- 
matism, synovitis,  pyelitis,  cardiac  lesions,  etc. 

Lastly,  there  is  one  complication  which  is  more  common  in  woman  than 
in  man:  stricture  of  the  rectum  {vide  p.  232). 

We  will  now  review  the  different  local  lesions  which  gonorrhea  produces 
in  women. 

Gonorrheal  Urethritis  in  Women. 

The  female  urethra  seldom  escapes  infection  when  a  woman  contracts 
gonorrhea.  During  intercourse  the  male  organ  is  in  intimate  contact  with 
the  vestibule  and  the  urinary  meatus  of  the  female,  and  thus  direct  con- 
tamination occurs  readily,  if  the  man  has  a  virulent  attack  of  gonorrhea. 

In  the  beginning  the  urethral  mucous  membrane  is  of  a  bright  red  colour. 
A  certain  degree  of  ectropion  is  common.  By  pressing  on  the  lower  wall 
of  the  urethra,  a  considerable  amount  of  greenish-yellow  pus  can  be  squeezed 
out  of  the  meatus.  Pressure  on  the  urethra  is  most  uncomfortable,  and 
natural  micturition  is  decidedly  painful.  Symptoms  of  cystitis  often 
supervene  at  an  early  date,  and  show  themselves  by  an  increased  frequency 
of  micturition. 

This  acute  stage  is  of  short  duration,  and  often  passes  off  without  having 
been  noticed  by  the  patient,  who  is  not  aware  of  any  trouble,  and  does  not 
complain  of  pain  or  any  other  symptom.  In  cases  of  this  kind  the  urethritis 
can  only  be  diagnosed  by  making  a  direct  examination.  One  introduces 
a  finger  into  the  vagina,  and  presses  from  behind  forwards  the  lower  wall 
of  the  urethra  against  the  posterior  surface  of  the  pubis.  One  obtains  in 
this  way  at  the  meatus  either  a  bead  of  pus  or  two  or  three  small  white 
specks,  which  represent  the  contents  of  inflamed  urethral  glands. 

The  technique  of  the  examination  of  the  female  urethra  has  already 
been  described  {vide  p.  113).  It  is  important  that  the  woman  should  not 
have  made  water  recently,  as  one  micturition  is  very  often  sufficient  to 


GONORRHEA  IN  WOMEN  AND  CHILDREN  253 

wash  away  all  the  gonococci  which  are  on  the  surface.  Hence  a  woman 
who  suffers  from  an  inflammation  of  her  urethra  may,  be  perfectly  harmless 
for  a  short  time  after  she  has  made  water,  whilst  she  is  virulent  if  inter- 
course takes  place  several  hours  after  the  last  micturition.  This  fact  also 
explains  the  possibility  of  a  woman  having  connection  with  several  men, 
and  contaminating  only  one  of  them.  In  this  respect  the  size  of  the  male 
organ  is  also  of  importance.  A  small  penis  may  not  exert  sufficient  pressure 
to  squeeze  the  morbid  secretions  out  of  the  urethral  glands,  whilst  a  large 
organ  is  most  likely  to  do  so,  and  will  probably  be  infected. 

The  intensity  of  the  orgasm  is  also  of  importance.  The  resulting 
hyperemia  is  apt. to  drive  any  latent  gonococci  which  may  be  hidden  in 
some  glandular  crypt  to  the  surface,  and  thus  to  favour  contamination. 

Nicolas  Massa's  rule  ("  Oportet  non  morari  in  coitu")  is  absolutely 
correct.  An  intercourse  is  ever  so  much  more  dangerous  the  longer,  slower, 
and  more  "  refined "  it  is.  Menstruation  is  also  not  without  influence. 
Some  women  are  only  infectious  during  their  periods,  owing  to  the  menstrual 
hyperemia  of  their  sexual  organs. 

The  Course  of  Gonorrheal  Urethritis  in  Women. — Gonorrheal  urethritis 
may  follow  one  of  the  two  following  courses :  Either  a  fibrous  urethritis 
ultimately  develops,  which  is  usually  regarded,  as  in  the  case  of  man,  as 
a  process  of  natural  cure — it  leads  to  the  formation  of  stricture;  or  a  'pro- 
liferating  urethritis  occurs  which  is  characterized  by  the  formation  of  little 
polypi.  These  vegetations  may  line  a  part  or  the  whole  of  the  urethra, 
and  are  often  accompanied  by  slight  hemorrhages  from  the  passage. 

In  Fig.  133,  which  is  drawn  from  Nature,  an  example  of  this  condition 
is  shown. 

In  other  instances  the  infection  extends  to  the  numerous  glands  which 
surround  the  female  urinary  meatus,  and  a  peri- urethritis  results. 

The  exasperating  tenacity  of  urethritis  in  women  is  due  to  the  great 
number  of  glands  which  are  situated  not  only  within  the  urethral  mucosa, 
but  also  in  the  mucous  surfaces  which  surround  the  meatus.  The  latter 
glands  are  of  special  importance. 

The  structure  of  the  mucous  membrane  is  exactly  the  same  in  man 
and  woman.  The  female  urethra  also  has  its  glandular  culs- de-sac  and 
diverticula  which  correspond  to  the  glands  of  Littre  and  the  lacunae  of 
Morgagni  in  the  male.  Moreover,  a  great  number  of  folhcular  glands 
arranged  in  two  lateral  groups  are  present  in  the  neighbourhood  of  the 
meatus.     Hamonic  has  given  a  good  description  of  them.^ 

Para-urethral  folliculitis,  a  frequent  mate  of  gonorrheal  urethritis,  is 
characterized  by  small,  red,  shiny,  shghtly  raised  spots  surrounding  the 

^  Hamonic,  "  La  Blennorragie  Genito-Urinaire  chez  la  Femme,"  Revue  Clinique 
(T Andrologie  et  de  Gynecdogie,  April  13,  1910,  p.  97. 


254 


GONOREHEA 


meatus.  When  pressure  is  made  on  them,  they  give  issue  to  a  little  drop 
of  pus  from  their  excretory  duct.  Occasionally  the  outer  surface  of  these 
glands  is  absolutely  normal,  and  yet  they  are  diseased.  They  should 
therefore  be  sought  for  systematically  in  all  cases  in  which  one  wishes  to 
form  an  accurate  idea  of  the  contagiosity  of  a  woman. 

These  folhcuhtes,  and  the  fistulee  which  are  frequently  found  in  con- 
nection with  them,  are  diagnosed  by  pressing  on  them  or  by  exploring  them 


Fig.  133. — Urethral  Polypi  in  Woman.     (From  Nature.) 


with  a  small  stylet.  One  often  finds  to  one's  surprise  that  a  minute  orifice 
which  has  barely  the  size  of  a  pin's  head,  and  only  gives  rise  to  an  infinitesimal 
amount  of  purulent  discharge,  leads  to  a  tract  in  which  the  stylet  passes 
several  centimetres. 

Gonorrheal  para-urethral  folhculitis  has  a  tendency  to  last  indefinitely, 
as  the  infection  becomes  locahzed  in  the  glandular  crypts,  from  which  it 
can  only  be  dislodged  with  the  greatest  difficulty.  Moreover,  the  small 
fistulse  which  are  the  sequelae  of  these  folhcular  abscesses  of  the  para- 


GONORRHEA  IN  WOMEN  AND  CHILDREN  255 

urethral  glands  never  heal  spontaneously.  They  are  apt  to  remain 
stationary  for  a  very  long  time. 

Para-urethral  folliculitis  is  sometimes  accompanied  by  small  abscesses 
in  the  vestibule,  which  burrow  their  way  more  or  less  deeply  into  the  tissues 
and  cause  great  mischief.  I  have  had  occasion  to  observe  two  cases  of 
such  para-urethral  abscesses  which  had  been  overlooked  by  other  medical 
men  and  specialists,  and  could  only  be  cured  after  a  well-directed  local 
therapy  had  been  instituted. 

Treatment  of  Gonorrheal  Urethritis  in  Women. — Gonorrhea  in  the 
female  should  be  treated  in  the  same  way  as  in  man. 


Fig.  134. — Janet's  SornsrD  foe.  Retrograde  Irrigation. 

A  similar  general  treatment  is  indicated,  and  the  same  hygienic  pre- 
cautions should  be  taken  {vide  Chapter  XI.). 

As  soon  as  possible  local  treatment  should  be  instituted,  and  this  therapy 
should  mainly  consist  of  irrigations  with  potassium  permanganate. 

Technique  of  Urethro- Vesical  Irrigations  in  Women. — One  should  always 
use  a  weak  solution  of  permanganate;  1  :  8,000  to  1 :  4,000  is  quite  sufficient. 

Before  beginning  the  lavage,  the  patient  should  pass  water  into  several 
glasses.  One  is  thus  able  to  see  if  the  first  glass  alone  is  turbid,  or  if  the 
turbidity  is  uniform. 

Once  the  bladder  is  completely  empty  the  patient  is  put  into  the  speculum 
position,  and  if  the  urethra  is  very  tender,  it  is  anesthetized  by  injecting 
a  few  cubic  centimetres  of  a  1  per  cent,  solution  o|  stovain  with  a  syringe. 
One  then  begins  the  irrigation. 


Fig.  135. — Ultzmann's  Sound  for  irrigating  the  Female  Urethra. 

A  special  nozzle  is  required  for  the  urethro- vesical  irrigations  in  women. 
The  best  models  are  those  of  Janet  and  of  Ultzmann.  The  irrigator  should 
be  about  3  to  5  feet  above  the  level  of  the  bed  or  couch.  One  introduces 
the  nozzle  gently  into  the  urethra,  and  washes  the  passage  with  the  per- 
manganate. One  then  gradually  passes  it  farther  along  the  urethra  until 
it  reaches  the  bladder.  By  moving  it  to  and  fro  the  whole  urethral  mucous 
membrane  can  be  cleansed  properly.  After  a  time  one  pushes  the  extremity 
of  the  instrument  into  the  bladder  and  fills  it  with  permanganate.  When 
the  desire  to  micturate  supervenes,  the  nozzle  is  withdrawn,  and  the  patient 


256  GONOKEHEA 

is  asked  to  pass  the  permanganate  solution  into  several  glasses.  This 
technique  allows  one  to  clean  the  urethral  mucous  membrane  very  thoroughly, 
as  the  washings  are  made  in  two  directions — from  before  backwards,  and 
from  behind  forwards. 

In  many  cases  it  is  possible  to  teach  the  patient  to  carry  out  this  treat- 
ment herself.  Seated  on  a  bidet,  with  her  thighs  well  flexed  and  her  body 
leaning  against  the  back  of  a  chair,  she  can  manage  to  find  her  meatus  by 
means  of  a  mirror  fixed  at  a  suitable  angle.  After  having  separated  her 
labia  minora  with  the  left  hand,  she  can  make  her  meatus  gape  and  carry 
out  the  irrigation  of  her  urethra  and  bladder. 

When  this  irrigation  treatment  has  been  used  for  a  few  days,  the  dis- 
charge ceases  and  the  urine  becomes  clear.  This,  however,  does  not  imply 
that  a  cure  has  been  effected.  Far  from  it,  and  this  is  the  most  common 
reason  for  the  tenacity  of  gonorrheal  infection  in  women. 

As  the  urethral  mucous  membrane  is  not  very  sensitive  in  women,  they 
do  not  worry  much  about  their  illness,  and  as  soon  as  they  realize  that  their 
urine  has  become  clear  again,  they  hasten  to  cut  short  their  treatment, 
with  the  result  that  in  most  cases  the  discharge  reappears  after  a  few  days. 
When  this  occurs,  one  can  be  practically  certain  that  a  definite  focus  is 
present  which  was  not  affected  by  the  irrigations.  One  should  locate  it 
by  means  of  the  urethroscope,  as  there  is  no  other  means  of  finding  it. 
The  female  urethra  is  very  short,  and  in  many  cases  the  urine  dribbles 
constantly.  It  is  therefore  best  to  use  Luys's  direct  vision  cystoscope 
instead  of  the  urethroscope.  Its  introduction  is  permissible  as  soon  as  the 
urine  has  become  clear  and  the  urethra  has  been  dilated  sufficiently 
{vide  Chapter  VIII.,  p.  182). 

By  means  of  this  instrument  the  areas  which  contain  the  gonococci,  and 
which  prolong  the  malady  indefinitely,  can  be  made  out.  Sometimes  one 
finds  a  little  lacuna  which  the  permanganate  irrigations  failed  to  reach; 
on  other  occasions  little  polypi  or  polypoid  vegetations  are  present  which 
shelter  the  gonococcus. 

It  is  always  advisable  to  make  a  urethroscopic  examination  as  soon 
as  possible.     How  necessary  it  is  may  be  seen  from  the  following  case: 

A  young  woman  came  to  consult  me  in  April,  1908,  almost  immediately  after  she 
had  been  infected.  She  had  a  definite  urethritis,  and  the  discharge  from  the  urethra 
contained  typical  gonococci.  There  was  no  morbid  secretion  from  the  cervix,  and 
scrapings  of  its  mucous  membrane  were  free  from  gonococci.  Ure  thro -vesical  lavage 
with  permanganate  was  restored  to,  and  after  a  few  days  it  rendered  the  meatus  dry 
and  the  urine  clear;  but  as  soon  as  this  treatment  was  discontinued  the  discharge 
reappeared,  and  was  of  considerable  amount. 

Two  anatomical  conditions  were  especially  unfavourable  in  this  case — firstly  the 
meatus  was  very  narrow,  and  secondly  a  marked  degree  of  cystocele  was  present,  owing 
to  which  the  meatus  lay  on  a  higher  level  than  the  urethra.     The  irrigations  were 


GONORRHEA  IN  WOMEN  AND  CHILDREN  257 

started  again,  and  were  combined  with  gradual  and  slow  dilatation  of  meatus  and 
urethra.  After  a  few  days  the  patient  could  be  urethroscoped,  and  now  a  small  focus 
was  discovered  on  the  lower  surface  of  the  urethra,  which  was  opened  by  means  of  the 
galvano -cautery,  and  then  destroyed  by  burning  it.  The  irrigations  were  now  dis- 
continued, but  the  discharge  reappeared  once  more.  I  therefore  examined  the  patient 
with  my  direct  vision  cystoscope.  The  urethra  was  found  to  be  quite  healthy,  but  I 
discovered  a  big  polypus  with  fleshy  excrescences  close  to  the  neck  of  the  bladder. 
As  this  papillomatous  condition  was  obviously  the  cause  of  the  recurrence  of  the  dis- 
charge, I  destroyed  it  with  the  cautery,  and  this  time  a  complete  cure  was  effected, 
the  beer  and  the  silver  nitrate  tests  being  both  negative. 

I  saw  the  patient  again  after  six  months.  She  had  remained  well.  The  meatus 
was  dry,  and  the  urine  was  clear. 

To  resume,  gonorrheal  urethritis  in  women  should  be  treated  in  the 
same  way  as  in  men.  At  the  beginning,  and  as  soon  as  possible,  urethro- 
vesical  irrigations  should  be  resorted  to.  Once  the  meatus  is  dry  and  the 
urine  clear,  the  urethra  has  to  be  gradually  dilated  with  short  straight  sounds, 
until  a  sufficient  degree  of  dilatation  is  reached  to  permit  of  the  introduction 
of  the  urethroscope.  The  subsequent  treatment  depends  upon  the  urethro- 
scopic  findings.  Thus,  some  cases  require  to  be  irrigated  and  dilated  by 
means  of  KoUmann's  irrigating  dilator,  whilst  others  demand  direct  local 
apphcations  (cautery,  silver  nitrate,  tincture  of  iodine,  etc.). 

This  is  the  truly  scientific  and  methodical  treatment  of  gonorrheal 
urethritis  in  women,  and  it  leads  to  a  certain  cure. 

This  being  so,  we  may  be  brief  in  our  description  of  the  various  thera- 
peutic measures  which  have  been  recommended  for  this  affection. 

Tamponade  of  the  Urethra  hy  Means  of  Mounted  Tampons  soaJced  in 
Ichthyol. — This  treatment  of  urethritis  in  women  has  at  one  time  been 
fashionable.  Small  swabs  which  were  firmly  mounted  on  sticks,  were 
soaked  in  pure  ichthyol,  and  passed  into  the  urethra.  One  left  them  there 
for  a  few  minutes,  and  then  withdrew  them.  This  therapy  was  undoubtedly- 
followed  by  a  certain  improvement  in  many  cases.  But  the  number  of 
relapses  was  endless,  and  thus  there  seems  little  justification  in  encouraging 
this  usually  inadequate  therapy.  The  use  of  balsam  preparations  (sandal- 
wood-oil,  cubebs,  copaiba,  etc.)  does  also  not  appear  to  have  given  any 
definite  and  complete  cures. 

Ecouvillonnage. — Verchere  has  recommended  to  brush  the  urethra  with 
little  tampons  held  by  a  pair  of  forceps.  These  swabs  were  soaked  in  a 
1  :  30  solution  of  silver  nitrate,  or  in  a  5  per  cent,  solution  of  zinc  chloride, 
or  in  corrosive  subhmate  of  a  strength  of  1  :  5,000.  One  rubbed  them  all 
over  the  urethral  mucous  membrane. 

This  treatment  cauterized  the  urethra  and  was  rather  painful.  In 
some  cases  it  was  followed  by  retention. 

Urethral  Suppositories  {Medicated  Bougies). — Urethral  suppositories  have 

been  recommended  by  Martineau,  who  used  medicated  bougies  containing 

17 


258  GONOEKHEA 

2  to  6  milligrammes  of  corrosive  sublimate.  One  of  them  was  to  be  intro- 
duced every  morning  after  the  bath,  and  to  be  retained  as  long  as  possible. 
They  were  most  irritating,  and  their  action  was  very  limited,  as  they  could 
not  influence  any  deeply-seated  infection  in  the  glandular  crypts. 

Bierhofi^  prescribed  suppositories  consisting  of  cocoa  butter  containing 
5  per  cent,  protargol.  They  were  to  be  used  after  the  urethra  had  been 
irrigated  with  a  1  :  4,000  solution  of  protargol,  and  were  retained  by 
means  of  a  T- bandage. 

The  treatment  of  chronic  urethritis  in  women  must  be  accompanied 
by  that  of  the  commonly  present  para-urethral  follicuhtis. 

For  the  cure  of  the  latter,  and  of  the  fistulae  which  so  often  result  from 
them,  a  series  of  injections  of  silver  nitrate  or  of  zinc  chloride  into  the 
glandular  orifices  has  been  recommended.  There  is  no  reason  why  one 
should  not  give  this  treatment  a  trial,  if  one  has  a  very  fine  and  blunt 
hypodermic  needle,  or  one  of  the  special  cannulas  invented  by  Janet  (Fig.  136), 
at  one's  disposal.  But  as  a  rule  this  therapy  gives  no  perfectly  satisfactory 
results. 

The  proper  treatment  of  these  para-urethral  folHcuhtes  is  the  one  which 
Diday  outhned  long  ago:  "The  true,  the  only  indication  is  to  provoke 


Fig.  136. — Janet's  Platino-Ikidium  Cannula  for  the  Para-Urethral  Ducts 

AND  Skene's  Glands. 

by  cauterization  the  obliteration  of  the  abnormal  cavity,  and  the  only 
method  which  is  of  any  use  for  this  purpose  is,  owing  to  the  narrowness  of 
the  passage,  the  introduction  of  a  metal  rod  at  red  heat." 

Even  to-day  this  method  appears  to  be  the  best  one,  especially  as  our 
modern  instrumental  outfit  is  greatly  improved  and  provides  us  with  finely- 
pointed  cautery  knives.  The  little  operation  itself  is  done  by  introducing 
a  very  sharp  cautery  blade  into  the  folhcle,  whilst  it  is  cool,  and  turning 
on  the  current.     The  fistulous  tract  is  thus  almost  instantaneously  destroyed. 

Gonorrheal  Vaginitis. 

The  presence  of  a  gonorrheal  vaginitis  seldom  passes  unnoticed.  The 
patient  discovers  a  more  or  less  profuse  flow  of  pus  from  her  vagina,  which 
is  often  accompanied  by  pain  on  moving.  Walking  becomes  troublesome, 
and  if  she  is  able  to  go  about,  she  walks  with  her  legs  apart  in  order  to  pre- 
vent her  painful  and  excoriated  parts  from  rubbing  against  each  other. 

^  Bierhoff,  New  York  Medical  Journal,  January  11,  1908. 


GONORRHEA  IN  WOMEN  AND  CHILDREN  259 

According  to  Verchere,  the  portions  of  the  vagina  which  are  most  often 
affected,  are  the  upper  part  of  the  posterior  wall  and  the  posterior  fornix, 
whilst  the  anterior  fornix  is  rarely  implicated.  This  locaUzation  is  supposed 
to  be  due  to  the  fact  that  the  uterus  is  the  chief  seat  of  infection.  For  this 
reason,  the  part  of  the  vagina  upon  which  the  cervix  rests,  the  posterior 
fornix,  is  the  most  diseased.  Moreover,  this  latter  structure  is  also  the  part 
most  likely  to  be  affected  by  direct  contamination.  It  is  in  this  fornix 
that  the  penis  deposits  the  contaminating  liquid. 

Verchere  ^  distinguishes  several  chnical  types  of  vaginitis : 

Congestive  Vaginitis. — The  whole  vaginal  mucous  membrane  is  bright 
red,  smooth,  and  glistening.  It  is  covered  by  an  adherent  mass  of  yellowish 
pus,  which  accumulates  in  the  vagina,  and  is  sometimes  retained  in  it.  Its 
presence  leads  to  a  marked  desquamation  of  the  vaginal  epithelium,  which 
is  characterized  by  a  very  adherent  caseous  and  fetid  coating  covering  the 
mucosa. 

Granular  Vaginitis. — In  this  condition  the  surface  of  the  mucous  mem- 
brane becomes  irregularly  roughened,  and  gives  the  palpating  finger  the 
same  sensation  as  a  cat's  tongue.  The  mucosa  is  studded  with  more  or  less 
extensive  granulations. 

Diphtheroid  Vaginitis  (croupous  vaginitis)  is  less  common,  and  is  charac- 
terized by  a  thick  yellowish- white  lardaceous  coating,  which  adheres  inti- 
mately to  the  vaginal  wall. 

The  treatment  of  gonorrheal  vaginitis  consists  mainly  in  vaginal  douches 
with  a  1  :  4,000  solution  of  permanganate,  and  should  be  completed  by 
dressings  which  are  destined  to  keep  the  inflamed  walls  of  the  passage  apart. 
Tampons  made  of  wool  which  have  been  impregnated  with  iodoform,  salol, 
or  glycerine,  are  useful  for  this  purpose. 

Gonorrheal  Metritis  (Cervicitis). 

According  to  Wertheim  and  to  Bumm,  the  gonococcus  remains  for  a  long 
time  in  the  uterus  after  it  has  disappeared  from  the  urethra  and  from  the 
vagina.  The  gonorrheal  inflammation  is,  however,  nearly  always  confined 
to  the  cervix.     Its  spreading  to  the  body  is  much  less  common. 

The  onset  of  gonorrheal  metritis  is  often  acute,  and  is  ushered  in  by 
pain  in  the  suprapubic  region  or  in  the  loins,  and  by  a  copious  dis- 
charge. 

On  examination  with  the  speculum,  the  mucosa  of  the  cervix  is  found 
to  be  pufly;  its  lips  are  everted  and  swollen;  the  circumference  of  the  os 
is  studded  with  .small  raised  patches  and  httle  ulcers.  Sometimes  these 
excoriations  coalesce,  and  form  one  large  ulcerated  surface.     For  cases  of 

^  Verchere,  La  Blennorragie  chez  la  Femme,  Paris  (Rueif),  1834. 


260  GONOEEHBA 

this  kind,  the  best  treatment  is  a  purely  antiphlogistic  one — rest  in  bed,  ice 
on  the  abdomen,  plenty  of  fluid  to  drink,  etc. 

The  chronic  form  is  much  more  common.  The  symptoms  of  chronic 
metritis  are  not  characteristic  of  the  illness.  The  periods  are  as  a  rule  more 
painful  a-nd  troublesome  than  they  were  previously.  They  are  irregular, 
and  come  on  before  their  time.  They  last  longer  than  normally,  and  often 
start  again  after  they  had  just  ceased.  There  is  more  or  less  marked  leu- 
corrhea.  The  cervix  is  large  and  swollen.  The  body  of  the  uterus  may 
become  implicated,  but  as  a  rule  the  cervix  alone  suffers. 

Gonorrheal  Endometritis. — An  endometritis  may  develop  as  a  result  of 
cervicitis. 

The  implication  of  the  body  of  the  uterus  in  the  gonorrheal  process  is 
characterized  by  general  malaise,  fever,  fatigue,  and  loss  of  appetite.  At 
the  same  time,  vague  diffuse  pains  in  the  lower  abdomen  are  complained  of. 
They  gradually  radiate  to  the  loins,  and  spread  all  over  the  abdomen. 

On  bimanual  palpation,  the  body  of  the  uterus  is  found  to  be  enlarged 
and  painful.  The  cervix  is  swollen  and  turgid,  and  gives  issue  to  a  per- 
manent purulent  discharge. 

Endometritis  nearly  always  becomes  chronic.  In  some  cases  the  inflam- 
mation of  the  womb  reaches  the  tubes.  An  acute  salpingitis,  or  suppurative 
ovaritis,  and  pelvic  peritonitis  with  all  its  sequelae,  or  pelvic  cellulitis,  are 
then  hable  to  supervene. 

Gonorrheal  metritis  is  a  benign  disease  in  itself.  But  its  complications 
render  the  prognosis  less  favourable,  and,  apart  from  those  already  men- 
tioned, ophthalmia  neonatorum  has  to  be  considered. 

In  the  beginning,  metritis  should  be  treated  by  means  of  vaginal  douches 
with  permanganate.  Vaginal  glycerine  tampons  are  not  of  much  use.  They 
bring  about  a  marked  decongestion  of  the  cervix,  but  they  have  no  effect 
upon  the  cavity  of  the  uterus. 

One  of  the  best  methods  of  treating  the  latter  consists  in  the  application 
of  Bier's  passive  congestion  therapy. 

One  uses  for  this  purpose  an  elongated  cupping-glass,  the  open  end  of 
which  is  placed  on  the  cervix.  Its  closed  extremity  is  connected  by  means 
of  rubber  tubing  with  a  syringe,  or  preferably  with  a  filter  pump,  which 
maintains  the  vacuum  automatically. 

The  use  of  this  instrument  is  very  simple.  The  vaginal  walls  are  held 
apart  by  means  of  a  speculum.  The  cup  is  then  brought  into  contact  with 
the  cervix,  and  suction  is  made,  as  long  as  it  is  left  in  position,  by  means  of 
a  syringe  or  a  filter  pump.  In  most  cases  the  application  lasts  five  minutes, 
and  may  be  repeated  every  other  day. 

The  aspiration  is  followed  by  the  evacuation  of  the  pus  and  slime  from 
the  cavity  of  the  cervix,  which  becomes  congested.     This  hyperemia  is 


GONORRHEA  IN  WOMEN  AND  CHILDREN  261 

recognizable  by  an  exudation  of  blood,  which  is,  however,  usually- 
slight.  ^ 

After  a  few  applications  the  uterus  is  found  to  be  less  congested,  and 
the  symptoms  are  amended. 

If  used  exclusively,  this  method  of  treating  gonorrheal  metritis  is  but 
moderately  successful,  but  it  gives  excellent  results  if  one  combines  it  with 
immediate  local  applications  to  the  cavity  of  the  cervix. 

It  is  therefore  well  to  proceed  in  the  following  manner:  Apply  the  cup, 
aspirate,  and  leave  it  on  for  five  to  ten  minutes.  Wipe  away  the  secretions 
thus  removed  from  the  cervix,  and  then  swab  its  whole  cavity  with  a  strong 
solution  of  permanganate  if  gonococci  are  present,  or  with  silver  nitrate  or 
zinc  chloride  if  the  cocci  have  disappeared. 


Fig.  137. — Uterine  Cup  and  Aspirator  for  Bier's  Treatment  op  Metritis. 

(Dr.  F.  Jayle.) 

In  certain  cases  this  treatment  can  be  usefully  completed  by  dilating 
the  cervix  with  Hegar's  bougies. 

Apart  from  the  general  treatment,  consisting  in  rest  in  bed,  hot  douches, 
etc.,  gonorrheal  endometritis  should  be  treated  by  local  measures.  Painting 
the  uterine  mucous  membrane  with  solutions  of  silver  nitrate,  tincture  of 
iodine,  zinc  chloride,  etc.,  gives  very  good  results,  but  it  seems  as  if  here 
also  dilatation  were  indicated.  Slow  and  far- pushed  dilatation  of  the  uterus 
and  prolonged  uterine  drainage,  combined  with  antiseptic  treatment  of  its 
cavity,  are  excellent  measures  against  gonorrheal  endometritis. 

Intra-uterine  irrigations  with  permanganate  can  be  resorted  to,  but  they 
cannot  he  recommended,  owing  to  their  danger.  Whatever  instruments  one 
may  be  using,  one  can  never  be  sure  of  the  pressure  of  the  liquid  inside  the 
uterus.  The  chances  of  the  fluid  being  under  pressure  inside  the  uterine 
cavity  are  therefore  very  great,  and  if  this  be  the  case,  it  tends  to  seek  an 

^  Jayle  and  Loewy,  "  Traitement  des  Metrites  par  Application  de  Ventouses  sur  le 
Col,"  Presse  Medicate,  December  14,  1907,  p.  813. 


262  GONOEKHEA 

outlet.     It  may  find  its  way  into  the  tubes,  and  may  even  reach  the  peri- 
toneum, bringing  on  collapse,  and  later  on  peritonitis.     Accidents  of  this  " 
kind  have  been  by  no  means  rare,  and  it  is  best  to  avoid  these  intra-uterine 
douchings. 

Intra-Uterine  Cauterizations. — Various  methods  of  cauterizing  the  uterine 
cavity  for  rebellious  gonorrheal  endometritis  have  been  used. 

In  the  first  place,  solid  caustics,  such  as  sticks  made  of  silver  nitrate 
(Courty),  have  been  employed.  Their  great  drawback  is  that  their  action 
is  blind.  A  caustic  substance  is  left  in  the  uterine  cavity,  which  may  either 
act  too  vigorously  or  too  little. 

DumontpalUer  and  Polaillon  advised  the  introduction  of  crayons  into 
the  uterine  cavity,  which  were  composed  of  Canquoin's  paste  (1  gramme  of 
zinc  chloride  for  2  to  3  grammes  of  flour  of  rye).  This  therapy  was  occa- 
sionally followed  by  the  formation  of  strictures  in  the  cervical  canal — so 
much  so  that  Professor  Pozzi  alone  had  to  relieve  two  cases  by  operation 
which  had  been  damaged  by  this  treatment. 

Liquid  caustics,  such  as  zinc  chloride,  weak  nitric  acid,  and  phenol,  may 
also  be  used,  but  only  after  a  previous  dilatation  of  the  cervix.  They  are 
apphed  by  means  of  mounted  swabs  which  have  been  saturated  with  them. 

The  instillation  of  a  caustic  is  carried  out  by  means  of  Braun's  intra- 
uterine syringe,  which  has  roughly  a  capacity  of  3  c.c.  Instillations  of  zinc 
chloride,  iron  perchloride,  tincture  of  iodine,  glycerine- creosote,  etc.,  have 
been  given  in  this  way,  and  some  have  been  very  satisfied  with  their  efEect 
— Professor  Pierre  Delbet,i  for  instance.  They  are,  however,  often  very 
painful.  Dr.  Siredy  has  given  intra-uterine  injections  consisting  of  a 
saturated  solution  of  picric  acid  by  means  of  Braun's  syringe. 

A  number  of  other  methods  have  been  advocated,  such  as  the  cauteriza- 
tion of  the  diseased  uterine  mucosa  with  superheated  air  (atmocausis). 
This  therapy  has  proved  disastrous  on  various  occasions.  Jayle  was  the 
first  to  recommend  thermo-insufflation  or  insufflation  of  hot  air  into  the 
uterine  cavity. 

The  Electric  Treatment  of  Metritis. — Electricity  has  been  resorted  to  in 
the  treatment  of  metritis,  in  France  especially  by  Apostoli,  in  the  form  of 
intra-uterine  electrolysis. 

An  electrode  is  placed  inside  the  womb — -this  intra-uterine  electrode  is 
a  massive,  semi-rigid,  semi-maUeable  stem  which  is  rounded  off  at  one  end, 
and  is  usually  made  of  some  non-corrosive  metal,  such  as  platinum — and  a 
second  one  is  applied  to  the  abdomen.  It  consists  of  a  pad  made  of  gauze 
or  lint  which  has  been  saturated  with  warm  saline  solution. 

If  a  trophic  action  on  the  uterine  mucosa  is  required — for  instance,  in 

^  Pierre  Delbet,  Ann.  de  Oynec.  et  d'Ohstetr.,  January,  1899;  and  in  Duplay  and 
Eeclus's  Traite  de  Chirurgie,  vol.  viii.,  p.  133. 


GONORRHEA  IN  WOMEN  AND  CHILDREN  263 

cases  of  old  torpid  metritis — the  negative  pole  is  connected  with  the  intra- 
uterine electrode,  and  a  current  of  30  to  60  milliamperes  is  allowed  to  pass 
for  four  to  five  minutes.  If  ionization  of  the  mucous  membrane  is  desired, 
the  positive  pole  is  connected  with  the  intra-uterine  electrode,  and  the 
negative  one  with  the  pad  on  the  abdomen. 

Various  metals  have  been  used  for  the  intra-uterine  electrode.  Popya- 
lowsky  uses  a  sound  made  of  zinc.  Dr.  Donnat  of  Pau  is  a  great  advocate 
of  ionization  treatment  for  gonorrheal  metritis.  He  uses  a  silver  sound, 
which  is  passed  into  the  uterine  cavity  and  connected  with  the  positive 
pole,  the  negative  one  being  connected  with  the  abdomen.  The  current 
should  vary  between  10  and  25  milliamperes,  and  should  be  discontinued 
after  five  to  ten  minutes.  At  this  moment  the  silver  electrode  is  firmly 
adherent  to  the  mucous  membrane  of  the  uterus,  but  it  can  be  freed  by 
reversing  the  current. 

Curetting. — When  the  metritis  is  far  advanced,  and  does  not  yield  to 
the  measures  outhned,  curettage  should  be  resorted  to.  In  acute  gonorrheal 
metritis  it  is  absolutely  contra-indicated,  for  it  would  expose  to  an  aggrava- 
tion of  the  affection  (Pozzi).^  It  is  indicated  only  when  all  other  measures 
have  failed. 

Lastly,  when  the  lesions  in  the  cervix  are  too  inveterate,  resection  of 
the  cervical  mucous  membrane  (Schroder's  operation)  is  advisable. 


Gonorrheal  Salpingo-Ovaritis. 

Gonorrheal  salpingitis  is  usually  insidious  in  its  onset.  In  most  cases 
the  woman  is  perfectly  unaware  of  her  illness,  and  only  reahzes  the  nature 
of  her  complaint  after  she  has  consulted  her  doctor. 

In  gonorrheal  salpingo- ovaritis,  bimanual  palpation  shows  the  ovary  to 
be  enlarged  and  displaced.  As  a  rule  it  has  moved  towards  the  uterus,  or 
dropped  into  Douglas's  pouch.  The  tube  is  felt  as  a  thick  well-defined  cord 
running  outwards  from  the  uterus  towards  the  brim  of  the  pelvis. 

The  functional  troubles  are  chiefly  menstrual — amenorrhea,  dysmenor- 
rhea, or  great  pain  during  the  menstruation. 

In  cases  of  salpingo- ovaritis,  it  is  essential  to  treat  the  metritis,  in  the 
same  way  as  it  is  necessary  in  the  case  of  man  to  treat  the  posterior  urethra 
when  an  epididymitis  is  present. 

In  suppurative  salpingitis  with  rapid  pulse  and  high  fever,  a  surgical 
intervention  by  the  abdominal  route  is  indicated  after  the  acute  inflam- 
matory phenomena  have  subsided. 

^  Pozzi  and  Jayle,  Traite  de  Gynecdogie,  Paris  (Masson),  1901,  4th  edit. 


264  GONORKHEA 


Gonococcal  Peritonitis. 

Gonococcal  peritonitis  is  the  outcome  of  the  spreading  of  the  inflamma- 
tion of  the  tubes  to  the  peritoneum. 

This  comphcation  is,  fortunately,  not  so  common  in  its  acute  form.  Its 
onset  is  often  fulminating.  The  patient  suddenly  feels  violent  pains  in 
her  abdomen,  which  are  accompanied  by  the  characteristic  symptoms  of 
acute  peritonitis — tympanites,  vomiting,  high  fever,  high  pulse-rate,  pinched, 
anxious  face,  prostration,  and  paralysis  of  the  bowels. 

The  chronic  form  is  much  more  frequent,  and  gives  rise  to  characteristic 
findings  on  vaginal  examination  and  bimanual  palpation.  Behind  the 
uterus  one  feels  a  hard,  resistant,  very  painful,  doughy  mass.  Cases  of  this 
kind  should  also  be  explored  per  rectum,  as  very  often  valuable  diagnostic 
information  can  be  gained  in  this  way. 

Gonococcal  peritonitis  is  characterized  by  its  irregular  course,  in  which 
exacerbations  of  variable  intensity  and  remissions  alternate,  and  its  dura- 
tion is  almost  unlimited.  Hence  quite  a  number  of  women  suffering  from 
this  affection  manage  to  pass  a  great  part  of  their  existence  on  a  sofa. 

It  is  permissible  to  begin  the  treatment,  as  in  the  case  of  salpingitis,  by 
treating  the  uterus.  Complete  rest  in  bed  and  copious  and  frequently 
repeated  hot  (or  even  very  hot)  douches  are  indicated  for  the  acute  attacks. 
The  apphcation  of  ice-bags  to  the  abdomen  is  often  very  useful  in  these 
cases,  but  as  soon  as  possible,  and  when  the  general  condition  of  the  patient 
allows  it,  an  operation  should  be  performed,  and  the  appendages  should  be 
removed. 

Gonorrheal  Bartholinitis. 

Gonorrheal  barthohnitis  is  usually  unilateral,  and  perhaps  more  common 
on  the  left  side.  In  the  beginning  of  the  gonorrheal  infection  the  inflam- 
mation of  one  of  Bartholin's  glands  becomes  evident  by  the  appearance 
of  a  swelling  on  the  lateral  part  of  the  vulva.  It  is  of  variable  size,  directed 
from  above  downwards,  and  covered  by  a  tense,  red,  smooth,  and  swollen 
mucous  membrane.  The  inflamed  gland  can  be  easily  felt  between  two 
fingers,  and  thus  its  consistence  and  volume,  and  the  permeabihty  of  its 
duct  can  be  made  out.  If  the  latter  is  patent,  a  greenish-yellow,  often 
fetid,  pus  often  escapes  from  the  gland  duct  on  slight  pressure  between  the 
two  fingers.  Once  the  acute  stage  has  passed  off,  the  inflammation  may 
become  chronic,  and  this  chronic  bartholinitis  is  one  of  the  most  common 
localizations  of  gonorrheal  infection  in  women.  The  orifice  of  the  duct 
may  give  issue  to  a  slight  intermittent  discharge,  and  subsequently  a  fistula 
may  develop ;  or  the  abscess  formed  may  burst  in  some  part  of  the  gland 


GONORRHEA  IN  WOMEN  AND  CHILDREN  265 

or  other,  and  lead  to  the  formation  of  a  fistulous  tract  of  variable  length, 
which  is  usually  sinuous. 

Gonorrheal  bartholinitis  is  most  tenacious,  and  apt  to  shelter  gonococci 
for  a  long  time.  After  the  acute  stage,  with  its  characteristic  findings,  has 
subsided,  there  may  be  merely  a  painless  lump  left,  which  does  not  worry 
the  patient.  One  should  therefore  make  it  a  matter  of  routine  to  look  for 
an  inflamed  gland  of  Bartholin,  especially  in  chronic  cases  in  which  the 
contagiousness  of  the  woman  has  to  be  decided.  By  palpating  the  labia 
majus  and  minus  between  thumb  and  index,  Bartholin's  gland  can  easily 
be  made  out.  In  chronic  bartholinitis  a  small  swelhng  of  the  size  of  a 
cherry  or  larger  is  palpable,  which  is  painless.  It  runs  away  under  the 
finger,  like  a  cherry-stone. 

Within  a  few  months  I  had  occasion  to  observe  two  absolutely  similar 
cases  of  gonorrheal  infection  of  Bartholin's  gland. 

In  the  first  one  I  had  to  deal  with  a  couple  who  had  been  together  for 
several  years.  After  having  been  separated  for  a  few  weeks  they  met  again, 
and  indulged  freely  in  sexual  intercourse.  A  few  days  later  the  man,  who 
so  far  had  been  free  from  any  gonorrheal  infection,  developed  a  profuse 
discharge,  which  was  full  of  gonococci.  The  woman  was  most  carefully 
examined,  but  no  gonococci  were  found  in  the  urethra,  para-urethral  ducts, 
cervix,  or  vagina.  I,  however,  discovered  that  she  was  suffering  from  a 
chronic  bartholinitis,  and  cured  her  by  excising  the  gland. 

The  second  case  is  almost  identical. 

It  would  thus  appear  that  chronic  inflammation  of  Bartholin's  glands 
is  of  the  same  importance  in  women  as  chronic  httritis  and  lacunitis  in 
man.  Like  the  latter,  they  often  harbour  the  gonococcus  for  a  considerable 
time  when  they  have  become  infected,  and  they  are  apt  to  give  rise  to 
sudden  recrudescences  after  long  intervals — many  months,  and  even  years. 
These  organs  should  therefore  always  be  examined,  and  treated  if  necessary. 

Acute  bartholinitis  is  best  treated  by  means  of  antiphlogistic  measures 
in  its  early  stage — hot  baths,  hot  injections,  etc.  Once  an  abscess  has 
formed,  the  knife  should  be  used  without  any  hesitation.  It  is  better  to 
excise  the  entire  gland  and  its  duct  than  to  make  a  simple  incision,  which 
would  probably  only  lead  to  a  partial  evacuation  of  the  infected  glandular 
pouches. 

It  is  permissible  to  inject  a  solution  of  permanganate  into  the  cavity  of 
the  gland  by  means  of  an  instillation  syringe  fitted  with  a  very  fine  needle, 
which  one  passes  into  the  duct  of  the  gland.  This  treatment  may  be  carried 
out  repeatedly,  and  may  be  combined  with  evacuatort  massage.  But 
efforts  of  this  kind  are  seldom  crowned  with  success,  and  then  the  surgical 
intervention  (incision,  or  preferably  excision)  becomes  necessary. 

The  operation  is  not  very  difficult.     Once  ons  has  rendered  the  gland 


266  GONOKKHEA 

prominent  and  incised  the  superficial  parts  on  the  inner  side  of  the  labium 
majus,  a  few  snips  with  a  pair  of  curved  scissors  free  it  from  the  neighbour- 
ing structures,  and  allow  it  to  be  shelled  out.  One  liberates  the  gland  in 
this  way  up  to  the  duct,  which  one  frees  as  much  as  possible.  The  latter 
is  then  ligatured  at  its  far  end.  In  certain  cases  the  gland  is  so  intimately 
adherent  to  its  surroundings  that  it  can  only  be  separated  with  difficulty, 
or  a  certain  amount  of  hemorrhage  may  take  place.  It  is  therefore  always 
a  wise  precaution  to  insert  a  small  drainage-tube,  which  is  left  in  situ  for 
twenty- four  hours. 

GONOKKHEA  IN  CHILDREN. 

Gonorrhea  is  by  no  means  rare  in  children.  Little  girls  are  more  often 
affected  than  little  boys. 

Wolbarst^  observed  personally  thirty-seven  boys  between  the  ages  of 
sixteen  months  and  fourteen  years  who  were  suffering  from  gonorrhea.  The 
greatest  incidence  of  the  infection  was  between  four  and  ten  years,  and  the 
diagnosis  was  established  by  microscopical  examinations,  which  demon- 
strated the  presence  of  gonococci. 

The  chief  indirect  causes  are  soiled  clothes  and  the  sharing  of  toilet 
articles.  Certain  parents  are  in  the  habit  of  taking  their  children  into  their 
bed,  even  when  they  are  suffering  from  gonorrhea.  Their  bedclothes  are 
soiled  with  the  virus,  and  contaminate  the  children.  The  infection  can  also 
be  conveyed  by  dressing  the  children  in  old  discarded  clothes  which  have 
been  infected.  Lastly,  the  common  use  of  surgical  instruments  may  be 
responsible.  Wolbarst  has  witnessed  the  case  of  a  little  boy  who  was 
infected  in  hospital  by  having  a  dirty  catheter  passed. 

Suchard^  quotes  an  epidemic  of  vulvo- vaginitis  which  broke  out  in 
Lavey.  Several  little  girls  were  infected.  The  epidemic  lasted  twelve  to 
fifteen  days,  and  was  only  stopped  after  the  common  swimming-bath  had 
been  disinfected. 

The  direct  causes  are  usually  to  be  found  in  precocious  intercourse.  This 
mode  of  infection  is  not  common  in  our  climates,  but  it  is  met  with  every 
day  amongst  the  negroes  in  South  America. 

De  Minine^  has  witnessed  many  cases  of  this  type.  The  black  children 
live  in  a  state  of  nudity,  and  often  indulge  in  sexual  games,  which  are  con- 
sidered natural  out  there.  They  are  viewed  in  the  same  Mght  as  the  play- 
fulness of  young  animals  in  which  the  rutting  instinct  is  developing. 

1  Wolbarst,  "  Gonococcus  Urethritis  in  Male  Children,"  Medical  Record,  October  29, 
1910,  p.  766. 

2  Bev.  de  la  Suisse  Romande,  November,  1877,  vii.  675. 

3  Minine,  Journ.  de  Med.  de  Paris,  June  8,  1895. 


GONORRHEA  IN  WOMEN  AND  CHILDREN  267 

It  is  occasionally,  however,  also  observed  in  Europe.  Dr.  Prat  of  Nice,^ 
for  instance,  has  published  a  case.  The  victim  in  question  was  a  boy  of 
four,  who  found  it  necessary  to  empty  his  bladder  whilst  he  was  playing 
with  several  other  children.  Too  lazy  to  undo  his  clothes,  he  asked  a  little 
girl  of  seven  to  assist  him.  The  young  monkey  jumped  at  the  opportunity, 
and  dragged  the  little  man  into  a  deserted  corner.  She  undid  his  clothes, 
lifted  up  her  skirts,  and  cuddled  him.  After  a  few  days  httle  Arthur  had 
great  pain  on  making  water,  and  his  mother  discovered  that  his  clothes 
were  soiled  with  pus  and  blood.  The  penis  was  violently  inflamed  and 
swollen.  The  desire  to  micturate  became  very  frequent,  and  the  pain  kept 
the  child  bathed  in  tears. 

Other  direct  causes  are  to  be  found  in  sexual  perversity,  such  as  sodomy 
and  the  intercourse  with  minors.  The  rape  of  little  girls  and  the  assaults 
committed  by  grown-up  women  on  httle  boys  are  important  sources  of 
infection.  The  last- mentioned  outrage  is  by  no  means  rare.  The  child's 
enemies  are  often  in  the  household  (maids,  governess,  etc.).  Dr.  Chaumier 
of  Tours  has  collected  eleven  cases  of  this  kind.^ 

Gonorrhea  in  Little  Boys. — Gonorrhea  takes  the  same  course  in  boys  as 
it  does  in  adults,  and  is  characterized  by  a  definitely  purulent  discharge. 
There  is  generally  considerable  inflammation  and  edema  of  the  prepuce. 
Retention  of  urine  is  also  not  uncommon.  The  latter  is  chiefly  due  to  the 
intense  pain  on  micturition,  which  frightens  the  child,  and  induces  him  to 
delay  the  act  to  the  last  moment. 

Gonorrhea  in  boys  may  heal  without  leaving  a  trace,  but  usually  some 
hall-mark  is  left,  such  as  a  stricture. 

Kammer  has  reported  on  a  boy  of  two  and  a  half  who  developed  reten- 
tion one  month  after  the  onset  of  his  illness.  He  was  found  to  be  suffering 
from  a  stricture,  through  which  not  even  the  smallest  sound  could  pass. 
The  bladder  had  therefore  to  be  punctured,  and  this  measure  had  to  be 
resorted  to  on  three  consecutive  days.  Under  ether  three  strictures  were 
discovered  in  the  anterior  urethra,  and  an  impassable  one  at  the  level  of 
the  membranous  portion. 

Amongst  the  other  complications,  purulent  ophthalmia  is  common. 
Cystitis  has  also  been  observed,  but  so  far  no  case  of  epididymitis  has  been 
reported  to  our  knowledge. 

Gonorrheal  rheumatism  of  the  acute  arthritis  type  has  also  been  known 
to  occur. 

As  a  rule,  these  compUcations  subside,  but  Wolbarst  has  met  with  a 
case  in  which  cachexia  and  death  supervened. 

^  Bull,  et  Mem.  de  la  Soc.  de  Med.  et  de  Climatol.,  vol.  xxxv.,  March,  1912,  p.  77. 
^  Edmond  Chaumier,  Etude  Clinique  sur  les  Maladies  des  Enfants,  Paris  (Asselin), 
1909. 


268  GONORKHEA 

The  treatment  is  the  same  as  for  adults.  Special  attention  should  be 
given  to  the  prepuce,  as  most  boys  have  a  certain  degree  of  phimosis. 

The  glans  and  the  balano- preputial  sulcus  should  be  kept  very  clean, 
and,  if  necessary,  circumcision  should  be  performed  without  hesitation,  in 
order  to  prevent  a  paraphimosis. 

Gonorrhea  in  Little  Girls. — In  little  girls  the  infection  may  escape  notice 
for  a  time,  but  sooner  or  later  a  profuse  vaginal  discharge  comes  on  which 
soils  the  hnen.  The  vulva  is  in  a  state  of  redness,  which  is  accompanied 
by  irritation,  and  often  by  hn  intense  erythema — vulvitis  of  little  girls. 

The  acute  symptoms  soon  subside,  and  make  room  for  a  chronic  con- 
dition, which  may  last  for  a  very  long  time.  In  fact,  the  grave  character 
of  this  disease  hes  in  its  long  duration  and  its  often  exasperating  rebelhous- 
ness  against  treatment. 

The  same  complications  as  in  boys,  such  as  cystitis  and  gonorrheal 
rheumatism,  are  also  found  in  little  girls. 

The  treatment  is  often  exceedingly  difficult.  The  parts  are  so  very 
narrow,  and  there  is  the  great  danger  of  the  disease  spreading  to  the  uterus. 
If  this  occurs,  one  is  confronted  with  a  very  difficult  task,  as  one  can  hardly 
reach  that  organ  when  the  hymen  is  intact. 

The  general  plan  of  treatment  is  the  same  as  for  adult  women.  Irriga- 
tions with  a  1  :  8,000  solution  of  permanganate  are  to  be  recommended. 


CHAPTER  XI 

THE  TREATMENT  OF  ACUTE  GONORRHEA 

Although  it  is  a  matter  of  daily  practice,  the  treatment  of  gonorrhea  is 
complex  and  difficult.  Both  the  patient  and  his  medical  ad^-iser  have  to 
devote  much  thought,  care  and  time  to  it.  It  is  essential  to  base  the  treat- 
ment on  a  rigorously  accurate  diagnosis  in  the  manner  outlined  above.  The 
object  of  all  therapy  must  be  to  applv  the  rational  treatment  which  they 
require  to  the  lesions  found  in  the  urethra,  and  for  this  purpose  the  ana- 
tomical and  pathological  findings  described  above  have  always  to  be  taken 
into  consideration  {vide  Chapter  V.). 

As  soon  as  the  gonococci  invade  the  urethral  mucosa,  a  reaction  takes 
place  which  is  characterized  by  a  dilatation  of  the  capillaries  and  the  dia- 
pedesis  of  a  countless  number  of  leucocytes,  which  tend  to  engulf  and  to 
destroy  the  organisms.  The  resulting  suppuration  is  thus  a  salutary 
measure  which  is  necessary  for  obtaining  a  cure. 

In  acute  confirmed  gonorrhea  the  treatment  should  never  aim  at  a  radical 
and  immediate  destruction  of  the  pathogenic  organisms.  Its  chief  and 
primary  object  should  consist  in  aiding  Nature's  efforts  and  not  in  opposing 
them. 

"We  know  that  during  the  fijst  hours  after  infection  the  gonococci  are 
on  the  surface  of  the  mucous  membrane,  and  that  they  very  soon — i.e., 
within  twenty-four  to  fortv- eight  hours  at  the  most — penetrate  between  the 
interstices  of  the  epithehal  cells  into  the  substance  of  the  mucous  membrane. 
Once  this  has  occurred — i.e..  four  days  after  the  infection  took  place — ^there 
can  be  no  hope  of  killing  the  organisms  immediately  by  means  of  injections 
or  irrigations.  The  gonococci  are  deeply  situated  in  the  mucosa,  and  are 
beyond  the  reach  of  any  antiseptics  which  one  may  pour  on  to  the  epitheHuni. 

We  have  to  consider — 

1.  The  prophylaxis  against  gonorrhea. 

2.  The  antiphlogistic  treatment. 

3.  The  treatment  of  conhrmed  gonorrhea, 

4.  The  abortive  treatment. 

5.  The  treatment  of  posterior  urethritis. 

6.  The  serum  therapy  of  gonorrhea. 

269 


270  GONOEEHEA 

1.  The  Prophylaxis  against  Gonorrhea. 

A  prophylactic  treatment  of  gonorrhea  is  evidently  the  most  satisfactory 
form  of  therapy.  To  know  the  evil  and  to  prevent  it  is  undoubtedly  the 
best  advice. 

In  the  case  of  gonorrhea,  the  human  brain  has  been  working  in  this 
direction  for  a  long  time,  alarmed  by  the  great  frequency  of  the  illness,  and 
of  its  sequelae,  which  are  so  often  disastrous. 

In  the  first  place,  the  factors  which  predispose  to  infection  should  be 
avoided.  Eicord  has  given  a  list  of  them  in  his  famous  recipe  (vide  p.  22). 
By  doing  exactly  the  opposite  of  his  instructions  one  is  able  to  diminish 
one's  chances  of  being  contaminated. 

In  suspicious  cases  one  should  finish  the  coitus  rapidly,  without  delay, 
ejaculate  promptly,  abstain  from  all  prolonged  excitation  and  repetition, 
and  avoid  all  causes  which  delay  the  ejaculations,  such  as  physical  fatigue 
and  inebriety.    These  are  excellent  precautions. 

Finger  has  dwelt  upon  the  importance  of  Littre's  glands,  situated  in 
the  anterior  urethra.  They  undergo  compression  during  each  erection, 
owing  to  the  vascular  engorgement.  An  alkaline  Uquid  is  thus  squeezed 
out  of  the  numerous  glandules,  which  appears  at  the  meatus :  urorrhea  ex 
libidine.  It  is  a  clear  viscous  fluid  which  is  secreted  in  variable  quantities, 
and  is  alkahne.  Any  trace  of  acid  left  in  the  canal  by  the  urine  passed  at 
the  last  micturition  is  thus  neutralized.  This  alkalinity  favours  the  vitality 
of  the  sperma,  which  passes  soon  after.  On  the  other  hand,  it  renders  the 
mucous  membrane  more  susceptible  to  gonococcal  infection.  It  becomes 
sodden,  and  loses  its  resisting  power,  and  thus  it  becomes  easier  for  the 
gonococcus  to  fix  itself  on  it  and  to  enter  its  substance. 

This  explains  why  immediate  micturition  after  coitus  often  successfully 
prevents  contamination.  The  urine  acidifies  again  the  urethra  as  it  is 
passed,  and  washes  away  the  infective  material.  It  may  even  kill  the  cocci 
deposited  on  the  mucous  surface.  Immediate  micturition  post  coitum,  and 
even  washings  of  the  glans  with  urine,  have  been  a  popular  prophylactic 
measure  against  gonorrhea  for  a  long  time. 

Further  precautions  of  value  are:  Before  intercourse  takes  place,  the 
woman  should  make  water,  take  a  vaginal  douche  with  1  :  10,000  perchloride 
of  mercury  solution,  and  introduce  a  vaginal  sponge  in  order  to  protect  the 
male  meatus  against  any  secretions  from  her  cervix.  Abstinence  from 
intercourse  during  and  immediately  after  the  periods  should  always  be 
insisted  upon,  as  a  flaring  up  of  the  infection  is  so  very  common  under  the 
circumstances.  With  these  precautions  one  is  in  most  cases  protected  against 
the  gonococcus. 

Apart  from  these  simple,  but  unfortunately  not  always  efficacious,  pro- 


THE  TREATMENT  OF  ACUTE  GONORRHEA      271 

phylactic  measures,  there  are  others  which  are  more  rehable,  and  have  been 
discussed  of  late  by  Janet, ^  namely: 

1.  The  condom,  French  letter  {capote  anglaise).  In  order  to  insure  pro- 
tection, it  should  neither  come  off  nor  burst.  There  are  many  men  who 
have  a  marked  aversion  against  its  use.  It  is  said  to  be  a  kind  of  cobweb 
against  the  danger,  and  an  armour  against  pleasure. 

Two  kinds  are  made — (1)  skins  and  (2)  rubber  letters.  The  former 
(baudruches)  are  made  from  the  csecum  of  sheep.  They  are  very  strong,  and 
last  for  a  long  time.  But  they  are  inelastic,  and  require  to  be  moistened 
when  appUed.  The  rubber  pouch  is  more  convenient,  but  it  is  thicker  and 
much  less  reliable.  Of  late,  the  swim-bladder  of  fishes  has  also  been  used 
for  making  French  letters.  They  are  the  thinnest  and  the  most  supple 
pattern,  but  they  tear  very  easily.  Certain  people  find  that  these  appliances 
inhibit  the  functions  of  their  generative  organs  to  such  an  extent  that  they 
cannot  possibly  use  them. 

Guiard^  has  rightly  called  attention  to  the  danger  of  accepting  pre- 
servatives offered  by  women.  They  not  infrequently  use  the  same  ones 
over  again,  and  thus  the  contamination  may  be  brought  on  directly  through 
their  use. 

2.  The  filhng  up  of  the  meatus  with  vaseline  before  connection  is  recom- 
mendable,  if  one  takes  care  to  withdraw  the  organ  immediately  after  ejacu- 
lation. 

3.  The  washing  of  the  glans,  meatus,  frenum,  and  scrotum,  with  soap, 
or,  better,  with  perchloride  of  mercury  and  soap,  immediately  after  the  act 
is  an  excellent  prophylactic  measure,  which  is  usually  successful  if  properly 
done.  The  soaping  should  be  as  complete  as  possible,  and  should  be  followed 
immediately  by  the  application  of  a  1  :  2,000  or  1  :  4,000  solution  of  corro- 
sive subhmate.     Tabloids  are  very  convenient  for  this  purpose. 

4.  Injections  of  antiseptics  by  means  of  a  syringe  immediately  after 
connection  are  to  be  avoided,  as  they  are  dangerous,  and  may  lead  to  acci- 
dents or  to  the  production  of  an  irritative  urethritis  in  inexperienced  hands.^ 

5.  Instillations  into  the  fossa  navicularis  of  a  few  drops  of  an  antiseptic 
solution,  such  as  20  per  cent,  protargol,  recommended  by  Frank  of  Berlin, 
seem,  on  the  other  hand,  to  represent  an  excellent  means  of  aborting  an 
attack  of  gonorrhea.     The  instruments  on  the  market  are — Blokusewski's^ 

^  Janet,  Revue  de  Thirap.  Med.-Chirurg. 

^  Guiard,  Traitement  Abortif  et  Prophylaxie  de  la  Blennorragie. 

2  This  view  is  not  shared  by  Guiard.  He  recommends  ten  injections  of  1  :  10,000 
permanganate  immediately  after  coitus.  A  syringe  of  20  c.c.  capacity  is  used,  and  this 
treatment  is  to  be  repeated  twice  or  three  times  during  the  day.  The  liquid  should, 
naturally,  only  fill  the  anterior  urethra. 

*  Blokusewski,  "  Zur  Verhiitung  der  Gonorrhoischen  Infektion,"  Dermat.  Zeits., 
1895,  No.  22;  1899,  No.  5. 


272  GONORRHEA 

"  Samariter,"  a  large  drop-bottle,  worked  by  means  of  a  rubber  membrane, 
which  contains  a  10  per  cent,  solution  of  albargin;  and  "  Viro,"  a  little  box 
with  six  paint  tubes  filled  with  20  per  cent,  protargol.  The  contents  of  a 
tube  are  squeezed  into  the  fossa  navicularis  after  coitus.  A  piece  of  the 
cotton-wool  contained  in  the  box  is  then  used  to  obturate  the  meatus  and  to 
prevent  the  hnen  from  being  soiled.^ 

Dr.  Grossed  advocates  oxycyanide  of  mercury  as  "  prophylacticum," 
and  has  devised  the  "  Selbstschutz,"  which  is  composed  of  two  parts:  a  tube 
of  the  size  of  a  pencil,  3  centimetres  long,  with  a  white  cap,  which  contains  a 
1  :  1,000  solution  of  oxycyanide  of  mercury,  and  another  tube  of  similar  size, 
with  a  red  cap,  containing  a  mixture  of  sterilized  lanoline  and  vaseline.  Before 
connection,  the  glans  and  prepuce  are  inuncted  with  the  vaseline  mixture, 
and  after  coitus  a  little  mercury  is  injected  into  the  urethra  and  retained  for 
a  minute.     The  remainder  of  the  solution  is  used  for  washing  the  parts. 

Drs.  Spitzer,^  Frank,^  ZeissL^  Steckel,^  Salmon  and  Rheuss,'''  have  also 
introduced  similar  contrivances  for  the  same  purpose.^ 

Henry  ^  recommends  the  following  formula : 

Calomel  . .  . .  . .  . .  . .  . .     50  grammes. 

Liquid  vaseline       . .  . .  . .  . .  . .     80  c.c. 

Lanoline  . .  . .  . .  . .  . .  . .     70  grammes. 

The  injection  of  this  mixture  is  carried  out  by  means  of  an  ordinary  glass 
syringe,  and  is  said  not  to  be  followed  by  any  irritation. 

Henry's  results  have  been  most  satisfactory.  Of  529  sailors  who  had 
exposed  themselves  to  infection,  only  four  acquired  gonorrhea. ^° 

All  these  prophylactic  measures  reduce  the  risks,  but  they  do  not  guarantee 
against  infection. 

2.  The  Antiphlogistic  Treatment  of  Acute  Gonorrhea. 

Antiphlogistic  treatment  is  not  destined  to  cure,  but  to  reheve.  As 
acute  gonorrhea  is  a  cyclic  disease,  its  course  should  not  be  interfered  with, 
but  favoured. 

1  Stordeur,  Rev.  Prat,  des  Mai.  des  Org.  Genito-Urin.,  Lille,  July  17,  1909. 

2  Grosse,  Miinch.  Med.  Woch.,  1905,  No.  2. 

3  Spitzer,  Allgem.  Wien.  Med.  Zeits.,  1907,  No.  2. 

4  Frank,  "  Zur  Prophylaxis  des  Trippers,"  Allgem.  Med.  Centr.  Zeits.,  1899,  No.  5. 

5  Zeissl,  Wien.  Med.  Woch.,  1901,  No.  8. 

6  Steckel,  Klin.  Therap.  Woch.,  1901. 

7  Salmon  and  Rheuss,  Med.  Moderne,  1903,  p.  404. 

8  The  text  of  the  original  gives  a  fuller  description  of  these  proprietary  articles. 
They  are  all  very  much  alike,  and  of  doubtful  value.  Moreover,  we  do  not  wish  to 
advertise  this  outcome  of  German  pharmaceutical  enterprise  (A.  F.). 

9  Henry,  The  Military  Surgeon,  vol.  xxx..  May,  1912,  p.  590. 

10  I  am  afraid  that  this  prophylaxis  is  based  on  views  belonging  to  the  pre-Hunterian 
period  (A.  F.). 


THE  TREATMENT  OF  ACUTE  GONORRHEA      273 

The  antiphlogistic  treatment  of  gonorrhea  was  one  of  the  first  to  be 
invented  and  to  be  used,  its  beneficial  effects  having  been  recognized  em- 
pirically a  long  time  ago.  It  has  been  chiefly  advocated  by  the  French 
school,  by  men  hke  Ciillerier,  Fournier,  Diday,  Horteloup,  Mauriac,  etc.  Its 
aim  is  to  facihtate  the  running,  and  it  even  favours  the  development  of  the 
gonococcus  in  the  initial  stage. 

Its  first  indication  is  to  remove  all  factors  which  could  influence  the 
disease  unfavourably.  Complete  rest  in  bed,  although  highly  desirable, 
will  seldom  be  consented  to,  and  thus  one  has  to  content  oneself  with  for- 
bidding all  violent  exercise  (running,  dancing,  gymnastics,  long  walks, 
swimming,  riding,  excursions  in  a  motor-car  or  on  a  cycle,  etc.). 

Suspensory  Bandage. — The  wearing  of  a  well- fitting  and  suitably  padded 
suspensory  bandage  is  to  be  recommended.  It  should  support  both  the 
penis  and  the  scrotum,  and  keep  them  at  rest  without  compressing  them. 

A  bandage  which  fixes  and  supports  the  scrotum  only,  is  not  sufficient, 
especially  in  acute  cases.  The  penis  also  requires  a  suspensory  bandage 
which  keeps  it  in  a  vertical  position.  The  normal  bend  of  the  urethra  at  the 
peno-scrotal  angle  is  a  point  of  lesser  resistance  in  which  lesions  are  apt  to 
develop.  Practical  experience  bears  out  this  fact;  for  one  commonly  finds  in 
chronic  cases  locahzed  diseased  areas  at  the  peno-scrotal  angle. 

It  is  therefore  necessary  to  do  away  with  this  curve.  The  ordinary  sus- 
pensory bandages  are  of  no  use  for  this  purpose ;  many  of  them  even  accentu- 
ate the  angle.  Paul  Asch^  therefore  rightly  recommends  the  use  of  a  special 
bandage,  by  means  of  which  the  penis  can  be  straightened  out  and  be 
attached  to  the  abdomen.  It  obliterates  the  peno-scrotal  angle,  and  prevents 
the  pus  from  being  pent  up  in  the  perineo-bulbous  portion. 

This  result  can  also  be  obtained  by  fixing  a  suitable  sheath  (like  the 
finger  of  a  glove)  to  an  ordinary  bandage.  The  penis  is  placed  into  the 
pouch,  which  is  attached  at  its  closed  end  to  a  ribbon  worn  around  the  neck. 
In  this  way  the  organ  is  kept  erect. ^ 

All  sexual  intercourse  should,  naturally,  be  strictly  forbidden.  The  same 
statement  holds  good  for  sexual  excitement,  and  therefore  thoughts,  pictures 
relating  to  sexual  matters,  lascivious  hterature,  female  company,  and  certain 
theatres  and  plays,  should  be  avoided. 

The  Diet  requires  careful  attention.  Spicy  and  indigestible  food  should 
be  avoided.  Very  acid  or  salty  dishes,  asparagus,  tomatoes,  game,  shellfish 
(lobster,  langouste,  etc.),  are  injurious.  In  a  few  words,  all  substances  which 
bring  about  constipation  or  excite  the  generative  organs  are  contra-indicated. 

^  Paul  Asch,  Ilikroscopische  Beitrdge  zur  Diagnose,  Therapie  und  Prognose  des 
Trippers  and  seiner  Folgen,  Berlin,  1907. 

2  Vide  also  Roucayrol,  "  De  I'Utilite  d'un  Suspensoir  de  la  Verge  dans  I'Uretrite 
Aigiie,"  ia  CTmig'Me,  December  27, 1907,  p.  829. 

18 


274  GONOEEHEA 

The  Intake  of  Fluid  should  also  be  regulated.  A  great  quantity  of  liquid 
is  one  of  the  best  means  of  diminishing  the  pain  during  micturition.  Un- 
diluted wine,  liqueurs,  beer,  cider,  whisky,  champagne,  aqua  vitse,  strong  tea 
and  coffee  are  harmful.  A  moderate  amount  of  wine  may  be  allowed  with 
the  meals,  if  it  is  well  diluted  with  water;  for  instance,  a  little  claret  in 
preference  to  burgundy,  mixed  with  plenty  of  Vittel  or  Evian,  or  a  shghtly 
alkahne  water  (eau  de  Pougues).  Highly  recommendable  are  certain  infu- 
sions made  from  plants,  such  as  dog's  tooth,  cherry  stalks,  or  buchu,  and 
fruit  syrups,  such  as  cherry,  raspberry  syrup,  etc. 

One  takes  a  glass  every  two  to  three  hours,  to  which  15  grains  of  sodium 
bicarbonate  have  been  added.  The  association  of  sodium  salicylate  and 
sodium  bicarbonate  is  also  excellent,  as  prescribed  by  Baker: 

Sodium  bicarbonate  , .  . .  . .  . .     30  grammes. 

Sodium  salicylate  . .  . .  . .  . .     10         ,, 

Two  teaspoons  of  this  powder  are  added  to  a  litre  of  lemonade  taken 
between  meals. 

Or  one  may  simply  prescribe  a  little  sahcylate  (2  to  3  grammes  per  day). 
Between  meals  the  infusion  is  taken.  One  of  the  best  is  the  one  made  from 
folia  uvse  ursi  according  to  Chevaher's  formula:  three  cups  per  day,  a  tea- 
spoon of  the  leaves  per  cup,  and  every  cup  is  flavoured  with  a  teaspoon 
of  the  following : 

Syrup  of  tolu   . .  . .  . .  . .  . .     300  grammes. 

Sodium  benzoate  ..  ..  ..  ..15         „ 

Tobacco  is  a  stimulant  to  non-smokers,  but  smokers  are  usually  immune 
in  this  respect,  and  therefore  there  is  no  need  to  forbid  its  use. 

The  patient  should  be  most  clean  in  regard  to  his  person.  He  should 
wash  his  hands  every  time  he  has  touched  his  penis,  and  should  be  very 
careful  not  to  bring  his  hands  near  his  eyes  when  they  are  soiled  with  pus, 
as  he  would  thus  expose  himself  to  the  danger  of  contracting  a  violent  con- 
junctivitis. It  is  best  to  cover  the  inflamed  meatus  with  frequently  renewed 
pieces  of  wool,  which  are  replaced  at  the  end  of  each  micturition.  Thorough 
cleansing  of  the  hands  every  time  the  generative  organs  have  been  touched 
must  be  insisted  upon. 

Warm  baths  of  long  duration,  say  at  97°,  and  lasting  forty-five  minutes, 
are  to  be  recommended,  and  should  be  taken  at  least  three  times  per  week. 
Local  washings  of  the  penis  should  be  made  with  hot  water,  as  hot  as  the 
patient  can  bear.  They  have  a  marked  decongestive  action.  In  some  cases 
ice- water  used  in  the  same  way  gives  excellent  results. 

The  genitals  should  be  kept  scrupulously  clean.  The  glans  should  be 
frequently  uncovered  and  be  carefully  washed,  as  well  as  the  balano-preputial 


THE  TREATMENT  OF  ACUTE  GONORRHEA      275 

fold.  One  has  often  observed  recurrences  in  patients  who,  unaccustomed 
to  cleanhness,  failed  to  wash  their  balano-preputial  sulcus. 

Urinary  AntiseTtics.^ — Urotropin,  or  one  of  its  substitutes  (uraseptine, 
helmitol,  urodonal,  etc.),  is  to  be  recommended  in  doses  of  1-5  to  2  grammes 
per  day. 

Local  Blood-letting  is  an  excellent  sedative  for  very  acute  cases,  and  gives 
marked  relief.  Fifteen  to  twenty  leeches  may  be  appHed  to  the  perineum 
for  that  purpose,  but  not  to  the  penis. 

Against  Erections. — Camphor,  in  the  form  of  bromide  of  camphor,  is  an 
excellent  sedative,  and  a  cachet,  containing  0-75  to  1  gramme,  may  be  pre- 
scribed, which  is  taken  half  an  hour  before  going  to  bed.  Belladonna, 
nenuphar,  lupulinum,  and  potassium  bromide,  have  but  an  uncertain  action. 
Opium,  either  pure  or  associated  with  antipyrin,  is  more  reliable,  and  is  best 
administered  as  an  enema  composed  of  warm  water,  10  to  20  drops  of 
laudanum,  and  1-5  to  2  grammes  of  antipyrin. 

Duration  of  the  Antiphlogistic  Treatment. — The  antiphlogistic  treatment 
should  be  carried  out  as  long  as  there  is  pain  during  micturition  and  during 
erection — i.e.,  usually  for  a  fortnight. 

3.  The  Treatment  of  Confirmed  Gonorrhea. 

The  local  treatment  is  nowadays  the  most  important  part  of  our  therapy 
for  gonorrhea.  The  medicinal  and  hygienic  presciptions  are  purely  adju- 
vants, although  they  are  very  useful. 

Various  methods  are  employed  for  the  local  treatment,  namely  : 

1.  Urethro- vesical  irrigations  without  a  catheter. 

2.  Injections. 

3.  Balsam  therapy. 

4.  Treatment  by  means  of  Bier's  method. 

Lastly,  there  are  some  special  points  in  connection  with  the  treatment  of 
acute  posterior  urethritis  which  will  be  dealt  with  separately. 

1.  Urethro -Vesical  Irrigations.- — These  irrigations  consist  in  the  passing 
of  a  liquid,  which  is  under  pressure,  over  the  whole  surface  of  the  urethral 
mucosa  into  the  bladder,  no  catheter  or  sound  being  used.  To  Janet  belongs 
the  credit  of  having  rendered  this  treatment  popular,  for  which  a  great 
number  of  drugs  had  been  advocated.     The  principal  ones  are  the  following : 

1.  Potassium  permanganate. 

2.  Silver  salts  :  nitrate  of  silver,  protargol,  albargin,  argyrol, 

argentamin,  argonin,  citrate  of  silver,  ichthargan. 

3.  Mercurial  salts:  perchloride,  oxycyanide,  cyanide. 

4.  Bismuth  salts:  subnitrate,  carbonate. 


276  GONOKRHBA 

Various  other  substances,  such  as  sodium  sahcylate,  hydrogen  peroxide 
picric  acid,  and  bile,  have  also  been  used  for  irrigating  the  urethra. 

As  we  will  discuss  the  merits  of  these  various  drugs  as  far  as  irrigation 
therapy  is  coiicerned,  later  on,  we  will  consider  for  the  moment  irrigations  with 
potassium  permanganate  only.  As  they  are  most  commonly  employed, 
they  will  be  described  more  fully,  and  may  serve  as  paradigm. 

The  Technique  of  TJrethro-Vesical  Irrigations  with  Permanganate. 

When  should  Cases  of  Acute  Gonorrhea  he  irrigated .?— There  is  a  divergency 
of  opinion  as  to  the  most  suitable  time  for  beginning  irrigation  treatment 
in  acute  gonorrhea.  Some  who  are  excessively  timid,  advise  to  wait  until 
fifteen  or  twenty-one  days  have  elapsed  since  the  beginning  of  the  disease. 
The  others,  who  are  more  enterprising,  begin  at  once — i.e.,  as  soon  as  the 
discharge  appears.  Those  who  are  best  advised,  adopt  an  intermediate 
course,  and,  in  agreement  with  them,  one  may  say  the  irrigations  should  he 
hegun  as  soon  as  fossihle,  when  there  are  no  contra-indications. 

Contra- Indication. — There  is  only  one  contra-indication  against  irrigation 
treatment  in  gonorrhea — namely,  a  very  acute  local  condition.  When 
the  meatus  is  markedly  edematous,  when  its  lips  are  red  and  turgid,  when 
micturition  and  erection  are  horribly  painful,  then  irrigations  are  contra- 
indicated.  They  would  under  these  conditions  merely  increase  the  pain, 
render  the  discharge  more  profuse,  and  cause  the  urethra  to  bleed.  Anti- 
phlogistic treatment  should  take  their  place  under  those  conditions. 

But  as  soon  as  the  acute  inflammatory  symptoms  have  subsided,  the 
irrigations  should  be  taken  up  again.  There  is  no  sense  in  "  watching"  a 
profuse  purulent  discharge  which  soils  everything,  tires  the  patient,  and 
remains  a  source  of  danger  to  its  owner  and  to  his  surroundings.  The 
immediate  well-being  experienced  by  the  patients  after  the  first  irrigations 
is  sufficient  proof  of  their  necessity  and  of  their  urgency. 

One  has  objected  that  irrigation  treatment  instituted  immediately  tends 
to  prolong  the  presence  of  the  gonococcus  on  the  urethral  mucosa,  and  that 
this  could  be  avoided  by  waiting  two  to  three  weeks  before  starting  the 
irrigations.  Statistics  have  even  been  put  forward  to  prove  that  the  disease 
lasts  longer  when  irrigation  treatment  is  resorted  to. 

This  objection  only  holds  good  for  those  cases  in  which  the  irrigations 
have  been  badly  carried  out  and  without  method,  or  when  the  patient  is 
troublesome.  It.  is  then  certainly  better  to  do  without  them.  But  a 
properly-given  irrigation  with  1  :  8,000  permanganate  should  enter  the 
bladder  without  difficulty.  Plenty  of  fluid  should  be  used,  and  the  irrigation 
should  be  repeated  often.  The  permanganate  can  always  be  made  to  enter 
the  bladder  easily  by  using  a  local  anesthetic  {vide  p.  280). 


THE  TREATMENT  OF  ACUTZ  GONORRHEA      277 

If  carried  out  in  this  fashion,  irrigations  never  give  rise  to  accidents. 
On  the  other  hand,  if  the  patient  contracts,  if  the  fluid  does  not  enter  the 
bladder  properly,  or  if  the  irrigations  are  painful,  then  nearly  always  com- 
plications arise,  such  as  epididymitis  and  prostatitis.  But  these  troubles 
are  never  met  with  when  the  irrigations  are  done  properly.  Carelessness  on 
the  part  of  the  patient  is  also  apt  to  bring  about  complications,  and  this  is 
by  no  means  a  rare  occurrence.  Violent  exercise  in  any  shape  and  form,  such 
as  cychng,  riding,  dancing,  and  excessive  drinking,  should  not  be  tolerated. 

On  the  Necessity  of  making  the  Liquid  enter  the  Bladder. — In  acute  gonor- 
rhea irrigations  are  only  of  value  if  they  pass  along  the  whole  channel. 

There  is  no  occasion  to  fear  that  the  bladder  could  be  injured  by  the  anti- 
gonococcal  solution  which  enters  it.  It  should  be  our  endeavour  in  every 
case  without  exception,  even  when  there  is  no  sign  of  a  posterior  urethritis, 
to  get  the  fluid  to  run  into  the  bladder.  The  risk  of  thus  infecting  the  deep 
parts  of  the  passage  exists  only  in  the  imagination  of  certain  people.  If 
the  liquid  carries  with  it  some  gonococci,  they  are  so  much  more  exposed 
to  its  action,  and  cannot  fail  to  undergo  destruction. 

Preparation  of  the  Solution. — The  water  used  for  irrigations  should  have 
been  boiled,  and,  if  possible,  be  distilled  water.  It  is  preferable  to  use  a 
warm  solution  instead  of  a  cold  one,  but  one  should  not  exaggerate;  the 
fluid  should  be  of  a  tepid  and  agreeable  temperature,  and  not  scalding. 
Cold  solutions  come,  so  to  say,  as  a  surprise,  and  cause  the  sphincter  to 
contract  and  to  prevent  the  fluid  from  reaching  the  bladder. 

In  the  beginning  very  dilute  solutions  should  be  used;  1  :  10,000  is 
sufficient  to  start  with.  One  then  gradually  increases  the  strength  to 
1  :  8,000,  and  proceeds  in  this  fashion  until  one  reaches  1  :  4,000,  or  0-25 
gramme  of  potassium  permanganate  per  litre.  To  go  beyond  this  strength 
is  seldom  necessary,  and  dilutions  of  1  :  2,000  and  1  :  1,000  are  rarely  used, 
especiafly  the  latter. 

For  making  up  the  solutions  one  can  use  tablets  or  small  packets  contain- 
ing the  required  dose ;  but  it  is  more  practical  for  the  medical  man  to  work 
with  a  mother  solution,  containing,  say,  10  per  cent,  of  permanganate. 
Every  cubic  centimetre  is  then  equivalent  to  O'l  gramme  of  permanganate, 
and  by  means  of  graduated  metric  measures  one  can  prepare  any  strength 
required  with  the  greatest  ease. 

A  1  per  cent,  mother  solution  gives  a  dilution  of  1  :  1,000  if  one  uses 
100  c.c.  of  it  per  litre.     For  a  dilution  of  1  :  2,000,  50  c.c.  have  to  be  used,  etc. 

This  question  of  dosage  must  become  a  matter  of  routine,  as  the  strengths 
have  to  be  varied  constantly  in  the  treatment  of  gonorrhea.  Three  symptoms 
of  the  greatest  importance  are  relied  on  for  the  dosage — -namely : 

1.  The  amount  of  discharge.  As  long  as  it  remains  copious,  the  solution  last 
used  was  either  too  weak,  or  too  long  an  interval  elapsed  between  the  irrigations. 


278 


GONOKEHEA 


1^, 


'i  ■  ft 


2.  The  examination  of  the  urine.  If  the  contents  of  the  first  glass  are 
turbid,  whilst  the  last  ones  are  clear,  the  solution  was  too  weak.  If,  on  the 
other  hand,  the  urine  contained  in  the  first  glasses  is  turbid,  and  also  in 
the  last  ones,  which  may  even  be  blood- streaked,  then 
the  irrigations  have  been  too  strong,  or  they  have  been 
repeated  too  often,  and  it  becomes  necessary  to  use  a 
weaker  dilution. 

3.  Functional  symptoms  characterized  by  pain  during 
and  after  micturition  are  also  precious  indications  for 
telling  if  the  urethra  has  reacted  to  the  irrigations. 

One  should  not  forget  that  in  some  cases  it  is  ex- 
tremely difficult  to  ascertain  if  the  pain  on  micturition  is 
due  to  the  drug,  or  if  it  is  simply  due  to  the  inflammatory 
reaction  set  up  by  the  presence  of  the  gonococcus  in  the 
urethra.  A  very  careful  analysis  of  all  the  symptoms  is 
then  required. 

Operative  Technique. — For  the  urethro- vesical  irriga- 
tions, an  irrigator  or  douche- can  of  1  to  1-5  litres  capacity 
is  usually  employed.  This  irrigator  is  either  fixed  to 
the  wall,  or  mounted  on  a  stand  which  allows  one  to 
raise  or  lower  it.  As  a  rule  a  position  3  to  5  feet  above 
the  level  of  the  bed  or  couch  is  sufficient.  The  irrigator 
is  connected  by  a  long  rubber  tube  with  a  cannula  such 
as  Janet's,  which  has  an  opening  of  2  millimetres.  The 
permanganate  should  always  be  used  in  a  warm  solution, 
preferably  38°  to  39°  C. 

The  patient  makes  water,  and  then  lies  down  on  the 
couch,  a  basin  being  placed  between  his  legs.  The 
glans,  the  prepuce,  and  the  balano-preputial  fold  are 
then  cleaned  with  an  antiseptic  solution. 

The  surgeon  seizes  the  glans  with  the  left  hand,  and 

holds  apart  the  lips  of  the  meatus,  whilst  his  right 

hand  brings  the  cannula  into  contact  with  the  orifice.     At  first,  the  anterior 

urethra  is  alone  irrigated  by  withdrawing  the  cannula  on  and  off  as  soon  as 

the  passage  is  filled,  and  before  there  is  any  great  pressure. 

When  the  anterior  urethra  has  been  well  cleansed — and  this  can  usually 
be  done  with  500  to  800  c.c. — the  point  of  the  cannula  is  introduced  into  the 
meatus,  and  pressed  against  it  in  order  to  close  the  canal.  The  patient  is 
then  requested  to  remain  quiet,  to  breathe  freely,  and  to  strain  a  bit,  as  if 
he  wished  to  make  water.  The  hquid  enters  the  bladder  under  these 
conditions  with  the  greatest  ease,  and  flows  until  the  patient  has  the  sensa- 
tion of  having  to  empty  his  bladder.     In  certain  cases,  however,  the  patient 


Fig.    138. — Ibriga- 

TOR  FOB  UbETHBO- 

Vesical     Irbiga- 

TIONS. 


THE  TREATMENT  OF  ACUTE  GONORRHEA 


279 


persists  in  contracting  his  sphincter  spasmodically,  and  prevents  the  Hquid 
from  flowing.  If  this  be  the  case,  one  can  lower  the  head  of  the  patient, 
or  bring  it  to  a  level  with  the  body,  or  one  can  ask  him  to  move  his  arms, 


Fig.  139.— Janet's  Cannula. 

imitating  artificial  respiration,  etc.,  and  very  generally  these  little  dodges 
will  have  the  desired  effect. 

The  flow  of  the  hquid  can  be  controlled,  if  a  small  air-bubble  is  in  the 


Fig.  140. — Ubethro-Vesical  Irrigations  without  a  Catheter. 

cannula,  by  the  appearance  of  little,  easily  recognizable  waves  when  the 
fluid  is  running  into  the  bladder. 
Another  means  of  telhng  that  the  fluid  is  passing  into  the  bladder  is  the 


280  GONOKRHEA 

wave-like  sensation  along  the  urethra  which  can  be  felt  with  the  left  hand. 
As  long  as  the  sphincter  is  contracted  and  prevents  the  fluid  from  passing, 
the  urethra  dilates  and  the  penis  swells.  Furthermore,  the  column  of 
Hquid  in  the  irrigator  diminishes,  and  the  patient  feels  that  something  is 
flowing  along  his  urethra  and  his  bladder  is  being  distended.  At  a  given 
moment  the  desire  to  make  water  supervenes.  The  cannula  is  then  with- 
drawn, and  the  patient  is  asked  to  make  water.  At  the  first  micturition 
the  permanganate  is  often  mixed  with  urine.  It  has  then  a  muddy  brown 
colour,  owing  to  the  reduction  of  the  salt  by  certain  constituents  of  the 
urine.  When  one  recommences  the  operation,  it  leaves  the  bladder  in 
the  same  condition  as  it  ran  in. 

On  the  Value  of  Local  Anesthesia  of  the  Urethra. — It  is  often  indispensable 
to  resort  to  a  local  anesthetic  for  urethro- vesical  irrigations.  Its  services 
are  immense  in  most  cases,  although  many  patients  do  not  require  it. 

Without  anesthesia,  urethral  irrigations  are  often  very  painful.  The 
sphincter  responds  by  an  energetic  contraction  which  stops  the  flow,  and  if 
under  these  conditions  one  raises  the  pressure,  one  only  makes  matters  worse. 
The  sphincter  replies  by  further  contractions,  the  permanganate  does  not 
begin  to  run,  but  the  urethra  becomes  twice  as  painful,  and  begins  to  bleed. 
The  subsequent  effect  is  an  exacerbation  of  the  inflammatory  symptoms. 

With  local  anesthesia  the  intervention  is  much  easier ;  the  solution  passes 
the  sphincter  almost  without  the  knowledge  of  the  patient,  and  gradually 
fills  the  bladder. 

Ten  c.c.  of  a  1  per  cent,  solution  of  stovain,  injected  into  the  anterior 
urethra  with  a  syringe  {vide  Fig.  103,  p.  151)  and  allowed  to  act  for  five 
minutes  or  so,  give  an  admirable  anesthesia  which  is  free  from  any  risk. 
Stovain  seems  preferable  to  cocain,  for  it  never  produces,  as  far  as  my 
experiences  goes,  malaise,  collapse,  or  any  of  the  other  disagreeable  sensa- 
tions which  occasionally  follow  upon  the  use  of  cocain.  One  should  also 
remember  that  a  number  of  cocain  disasters  have  been  published,  in  which 
an  acute  intoxication  characterized  by  collapse,  cold  sweats,  syncope,  or  a 
chronic  poisoning  known  as  "  cocain  delirium,"  supervened. 

Some  patients  complain  of  pain,  despite  the  stovain  injected  into  their 
anterior  urethra.  This  pain  is,  however,  not  located  in  the  canal  itself,  but 
is  the  result  of  the  pressure  of  the  glass  nozzle  on  the  inflamed  meatus  and 
fossa  navicularis.  In  some  cases  this  pain  is  so  severe  that  the  irrigations 
have  to  be  temporarily  discontinued. 

This  trouble  can  also  be  avoided  if  one  soaks  a  mounted  swab  in  a  10  per 
cent,  solution  of  stovain,  and  introduces  it  through  the  meatus  as  far  as  the 
fossa  navicularis,  where  it  is  left  for  a  few  minutes.  If  necessary,  this  pro- 
cedure may  be  repeated  a  few  times;  it  allows  one  to  reheve  all  pain,  and 
then  the  irrigation  can  be  given  without  any  difficulty. 


THE  TREATMENT  OF  ACUTE  GONORRHEA      281 

Should  one  use  an  Irrigator  or  a  Syringe  ? —  Urethral  Lavage  with  a 
Syringe. — Some  practitioners  prefer  the  syringe,  and  others  the  irrigator. 
In  most  cases  an  irrigator  seems  preferable,  as  it  gives  a  continuous,  even 
flow,  whilst  manipulations  with  a  syringe  are  always  irregular  and  jerky. 
An  irrigator  is  most  satisfactory,  especially  if  one  injects  previously  a  little 
stovain  as  indicated.  However,  chiefly  in  nervous  patients,  who  tightly 
contract  their  sphincter,  and  thus  prevent  the  fluid  from  reaching  their 
posterior  urethra  and  their  bladder,  irrigation  with  a  syringe  is  often  of 
great  service. 

When,  for  instance,  despite  the  injection  of  stovain  and  the  pressure 
of  the  column  of  fluid  from  the  irrigator,  the  sphincter  refuses  to  peld, 
although  the  patient  has  been  asked  to  keep  himself  relaxed  and  to  breathe 
quietly,  as  if  he  were  asleep,  then  it  is  unreasonable  to  insist.      One  is  bound 


Fig.  141. — Luys's  Syringe  of  100  C.C.  Capacity. 
Its  piston  is  made  of  earth-flax,  and  the  whole  can  be  sterilized  by  boiling. 

to  do  the  patient  more  harm  than  good.  The  anterior  urethra  is  abnormally 
distended,  the  sphincter  is  in  a  state  of  spasm,  and  the  mucous  membrane 
usually  begins  to  bleed. 

If  one  discards  the  irrigator  in  cases  of  this  kind,  and  uses  a  syringe 
instead,  one  often  finds  to  one's  surprise  that  the  fluid  enters  the  posterior 
urethra  without  any  difficulty,  even  in  the  absence  of  great  pressure  and 
local  anesthesia. 

It  is  sufficient  in  these  cases  to  press  the  piston  of  a  syringe  of  100  c.c. 
capacity  gently  home  for  a  short  distance  in  order  to  drive  the  hquid  into 
the  bladder. 

The  resistance  of  the  sphincter  can  be  overcome  in  nearly  every  instance 
by  this  means;  but  this  is  not  achieved  by  force.  The  value  of  the  syringe 
lies  in  this  fact,  that  it  allows  one  to  surprise  the  sphincter  when  it  relaxes, 
and  to  "  sneak  the  fluid  in  "  rather  than  to  inject  it.  The  muscle  is  not  in 
a  state  of  permanent  contraction.  Its  contractions  are  intermittent,  and 
the  intervals  must  be  taken  advantage  of  in  order  to  inject  the  fluid  with 
"  an  extremely  light  thumb  "  (Guiard). 

The  pressure  should  be  varied  constantly;  sometimes  it  should  be  very 
weak,  then  again  more  vigorous.     At  times  it  should  be  jerky,  and  at  others 


282  GONOEKHEA 

continuous  and  sustained.  In  this  way  all  obstacles  are  ultimately  over- 
come. After  a  while  the  patients  become  accustomed  to  having  fluid 
injected  into  their  bladders  in  this  fashion,  and  then  one  can  go  back  to  the 
irrigator  without  experiencing  any  further  difficulties. 

The  use  of  a  syringe  is  not  without  danger.  If  used  gently  and  carefully, 
the  sphincter  can  be  gradually  overcome  at  the  right  moment,  but  if  the 
manipulations  are  brutal  and  violent,  the  patient  is  submitted  to  unneces- 
sary suffering,  and  considerable  injury  can  be  done  to  the  walls  of  his  urethra. 
To  resume,  the  use  of  a  syringe  is  only  justifiable  in  the  hands  of  a  highly 
experienced  and  skilful  practitioner  who  is  gifted  with  a  hght  touch. 

Should  a  Catheter  he  used  for  Urethro-Vesical  Irrigations  ? — Diday  ad- 
vocated for  certain  difficult  cases  to  pass  a  catheter  into  the  urethra  and  to 
irrigate  through  it.  It  did  not  matter  much  how  far  the  instrument  was 
introduced,  and  whether  it  passed  the  sphincter  or  not,  as  experience  had 
shown  that  very  often  the  fluid  entered  the  bladder  without  great  difficulty, 
if  the  point  of  the  catheter  was  lying  in  front  of  the  membranous  region. 

De  Pezzer  invented  short  catheters  of  a  small  diameter  which  were 
perforated  by  three  rows  of  little  holes  arranged  at  angles  of  120  degrees 
over  a  length  of  5  centimetres. 

Duchastelet^  took  up  this  method,  and  became  one  of  its  most  ardent 
advocates.  In  the  course  of  six  years  he  never  saw  any  untoward  effect 
(orchitis  or  retention  or  the  slightest  trouble  on  micturition).  He  used 
rubber  catheters  of  a  special  make,  which  he  called  "  sondules."  Those  for 
the  anterior  urethra  were  straight,  and  those  for  the  posterior  coude.  They 
had  one  large  eye  close  to  their  end  through  which  the  irrigation  fluid  passed 
rapidly.  Duchastelet  claimed  that  the  urethra  thus  never  became  dis- 
tended, and  that  these  irrigations  could  be  carried  out  by  the  patient.  He 
said:  "The  slender  sondule  makes  its  way  within  a  vein  of  fluid  which  sur- 
rounds and  precedes  it."  It  opens  out  the  virtual  cavity  of  the  urethra  in 
accordance  with  the  physiological  tolerance  of  the  open  passage. 

There  is  no  doubt  that  this  method  is  of  value  in  certain  cases — for 
instance,  if  the  patients  are  very  nervous  and  if  the  spasm  of  the  sphincter 
is  difficult  to  overcome.  But  it  does  not  seem  probable  that  this  method 
will  ever  replace  the  irrigations  without  a  catheter,  which  will  always  remain 
the  method  of  choice. 

'What  Intervals  should  elapse  between  the  Irrigations  ? — It  is  always 
preferable  to  irrigate  frequently,  using  plenty  of  fluid  and  a  solution  of 
suitable  strength,  than  to  give  a  few  irrigations  with  a  small  amount  of  highly 
concentrated  solution.  It  is  advisable  to  entrust  the  patient  with  these 
irrigations  after  he  has  become  familiar  with  their  technique.     He  can  then 

1  Duchastelet,  C.  B.  de  VAss.  FrauQ.  d'Urol,  1906,  p.  216. 


THE  TREATMENT  OF  ACUTE  GONORRHEA      283 

cleanse  himself  twice  daily  at  twelve  hours'  interval  with  a  1  :  8,000  solution 
to  his  best  advantage. 

After-Effects  of  the  Irrigations. — In  most  cases  urethro-vesical  irrigations 
with  permanganate,  if  properly  done,  cause  no  appreciable  suffering.  At 
the  most  the  patient  may  find  his  urethra  hot,  or  he  may  complain  of  slight 
heaviness  about  the  perineum,  or  display  a  httle  vesical  tenesmus  for  an 
hour  or  so. 

How  Long  should  these  Irrigations  he  Continued  ? — These  irrigations  are 
indicated  as  long  as  a  discharge  is  present,  and  as  long  as  the  urine  contained 
in  the  first  glass  remains  turbid.  As  a  rule,  it  is  necessary  to  irrigate  once 
or  twice  daily  for  fully  two  weeks.  After  that  period  one  may  wash  every 
other  day,  or  every  four  days,  and  finally  once  a  week.  When  the  patient 
has  been  eight  days  without  irrigations  and  shows  no  discharge,  the  treat- 
ment may  be  discontinued. 

At  the  end  of  every  irrigation  the  hands  of  the  surgeon  and  the  parts 
of  the  patient  are  usually  stained  with  permanganate.  Their  normal  colour 
is  easily  restored  by  applying  a  concentrated  solution  of  sodium  bisulphite. 

The  Action  of  Permanganate. — Permanganate  of  potassium  seems  to  be 
superior  to  any  other  drug  owing  to  its  remarkably  powerful  action  on  the 
gonococcus.  Its  use  is  therefore  indicated  every  time  the  microscope 
shows  the  presence  of  Neisser's  organism  in  the  discharge.  For  cases  of 
this  kind  potassium  permanganate  is  perfect,  and  gives  splendid  results  if 
one  knows  how  to  use  it. 

The  doses  mostly  employed  vary  between  1  : 4,000  and  1  : 8,000. 
The  success  depends  on  a  judicious  choice  of  the  right  strength  for  each 
individual  case. 

Permanganate  was  introduced  by  Condy  in  1857,  who  recommended  it 
as  an  antiseptic.  In  1864  Rich  and  Van  den  Corput  used  it  for  urethral 
injections.  Zeissl  of  Vienna  and  Spillmann  of  Nancy  tried  it  in  1879. 
Gourgues  (1889)  used  it  on  women.  Reverdin  in  1885  adopted  it  for  irri- 
gating men  through  a  soft  catheter,  which  he  introduced  as  far  as  the  bulb. 
Janet  made  wide  use  of  this  drug  in  1889,  and  his  writings  led  to  its  universal 
recognition  as  a  drug  for  the  treatment  of  gonorrhea. 

It  is  nowadays  certain  that  potassium  permanganate  has  a  truly  elective 
action  upon  the  gonococcus,  and  that  this  beneficial  effect  is  not  due  to  its 
antiseptic  power,  which  is  insignificant  in  higher  dilutions  than  1 :  1,000. 

If  its  wonderful  effect  in  gonorrhea  is  not  solely  due  to  its  action  on  the 
gonococcus,  one  has  to  consider  the  possibility  of  a  special  influence  on  the 
urethral  mucous  membrane. 

I  have  often  been  struck  by  its  constricting  action  upon  the  urethral 
mucosa.  If  one  attempts,  after  having  irrigated  with  permanganate,  to 
pass^  an   instrument  into  a  normal  urethra,  one  notes  a  very  definite  r^- 


284  GONORRHEA 

sistance,  even  if  the  instrument  is  very  well  lubricated.  In  the  case  of  an 
irrigating  dilator,  one  commonly  finds,  if  one  has  irrigated  with  perman- 
ganate through  it  after  its  introduction,  that  one  can  hardly  withdraw  it. 
It  is  firmly  gripped,  and  seems  to  have  contracted  adhesions  with  the  mucous 
membrane.  One  never  makes  this  observation  after  the  use  of  boric  lotion 
or  oxycyanide  of  mercury  solution.  It  would  thus  appear  that  one  should 
take  this  constricting  effect  on  the  mucous  membrane  into  consideration. 
As  the  mucosa  is  being  made  to  shrivel  up,  a  regular  massage  of  the  glands  of 
Littre  and  the  lacunae  of  Morgagni  takes  place,  which  empties  their  contents. 
The  permanganate  has,  however,  also  a  decided  action  on  the  gonococcus. 

Janet  has  pointed  out  this  fact  with  great  clearness,  and  has  shown  that 
permanganate  produces  a  slight  serous  reaction,  which,  however,  is  durable, 
and  is  accompanied  by  a  mild  edema  of  the  mucosa.  "  As  long  as  this 
state  of  things  lasts,  it  is  impossible  to  find  any  cocci  in  the  urethral  secre- 
tions, and  if  one  maintains  this  condition  of  the  urethra  long  enough,  the 
destruction  of  the  organisms  is  assured." 

The  permanganate  treatment  should,  therefore,  aim  at  producing  a 
brown  urethral  secretion,  which  makes  the  canal  a  bad  soil  for  the  gonococcus. 

To  chose  the  proper  quantity,  to  find  the  correct  strength,  and  to  give 
the  right  number  for  producing  this  brown  reaction  after  every  irrigation— 
herein  lies  the  art. 

Failures  occur  under  the  following  conditions : 

1.  When  the  intervals  between  the  irrigations  are  too  long. 

2.  When  the  solutions  are  too  strong. 

3.  When  the  patient  resumes  his  sexual  activity  too  soon,  or  neglects 
the  necessary  dietary  rules. 

4.  When  para-urethral  foci  are  present  which  the  irrigations  cannot  reach. 
In  the  last- mentioned  case,  these  para-urethral  localizations,  which  Janet 

has  so  well  described,  should  be  explored,  and  also  the  fistulas  so  commonly 
present  in  men  suffering  from  hypospadias.  The  same  may  be  said  of  the 
prostate,  which  is  palpated  per  rectum,  and  of  Cowper's  glands. 

Lesions  in  these  structures  are  the  commonest  causes  of  insuccess,  and 
a  minute  examination  of  all  the  glands  connected  with  the  urethra  becomes 
imperative  whenever  a  discharge  containing  gonococci  is  left  after  ten  to 
twenty  irrigations  which  were  given  properly  and  at  suitable  intervals. 

On  the  Other  Substances  used  for  Urethro-Vesical  Irrigations. 

Silver  nitrate  is  seldom  indicated  in  the  treatment  of  confirmed  gonor- 
rhea. It  is  unquestionable  that  this  drug  has  a  marked  action  on  the 
gonococcus.  Daily  experience  tells  us  that  an  irrigation  with  silver  nitrate 
IS  sufficient  to  bring  on  a  discharge,  containing  plenty  of  gonococci,  which 


THE  TREATMENT  OF  ACUTE  GONORRHEA      285 

shows  itself  on  the  next  day  or  the  day  following  in  cases  which  showed  no 
longer  any  gonococci  in  their  urethral  secretion.  For  this  reason,  silver 
nitrate  should  only  be  used  in  order  to  ascertain  whether  the  urethra  is  com- 
pletely freed  from  gonococci  or  not.     This  is  the  "  silver  nitrate  test." 

So  far  no  satisfactory  explanation  has  been  given  for  this  curious  prop- 
erty of  silver  nitrate  to  resurrect  the  gonococci  after  they  had  apparently 
completely  vanished.  The  most  rational  view,  which  is  based  upon  per- 
sonal experience  with  the  urethroscope,  is  the  following: 

If  one  apphes,  under  the  control  of  the  urethroscope,  silver  nitrate  in 
a  more  or  less  concentrated  form  to  the  urethral  mucosa,  one  sees  that  the 
latter  contracts  violently,  and  becomes  markedly  corrugated.  It  thus 
becomes,  after  the  silver  nitrate  has  been  applied,  almost  impossible  to  move 
the  urethroscope  farther  on  in  the  part  which  has  been  cauterized.  One  is 
checked  by  a  vigorous  contraction,  which  in  many  cases  cannot  be  over- 
come. From  this  one  may  conclude  that  silver  nitrate  acts  chiefly  by 
causing  the  muscular  fibrillae  of  the  mucosa  to  contract. 

In  this  way  the  various  crypts  (lacunae  of  Morgagni  and  glands  of  Littre), 
in  which  the  gonoccoci  are  hidden,  are  partially  emptied,  and  the  organisms 
come  to  the  surface.  To  resume,  silver  nitrate  is  never  to  be  recommended 
for  irrigations  in  confirmed  gonorrhea;  but  it  is  a  most  valuable  drug  in  the 
treatment  of  gleet. 

Alhargin  is  very  widely  used  in  Germany,  where  it  is  preferred  to  per- 
manganate. It  is  a  silver  albuminate,  and  is  decomposed  by  light,  Uke  all 
silver  salts.  Unhke  the  nitrate,  it  does  not  form  a  coagulum  when  it  comes 
into  contact  with  the  urethral  mucous  membrane;  this  advantage  it  shares 
with  the  other  organic  compounds  of  silver.  It  compares  favourably  with 
protargol,  as  it  decomposes  less  readily  and  can  be  used  in  warm  solutions 
- — an  impossibihty  with  protargol;  moreover,  it  is  cheaper. 

It  has  an  undoubted  bactericidal  action  upon  the  gonococcus,  and  a 
trial  in  many  cases  has  shown  me  that  it  causes  these  organisms  to  dis- 
appear rapidly  from  the  discharges  which  contained  them  previously.  It 
is,  however,  also  true  that,  despite  repeated  irrigations  with  this  substance, 
the  discharge  fails  to  stop  soon,  although  it  may  be  microscopically  free 
from  gonococci,  whilst  permanganate  used  at  this  stage  works  wonders. 

A  considerable  quantity  of  albargin,  even  in  a  strength  of  1 :  1,000,  is 
practically  always  painless;  its  use  is  indicated,  therefore,  in  certain  cases 
where  the  permanganate  irrigations  are  excessively  painful.  If  after  five 
or  six  albargin  irrigations  the  discharge  remains  copious,  permanganate 
may  again  be  resorted  to  with  the  greatest  benefit. 

Protargol  should,  according  to  Neisser  and  Barlow,^  be  preferred  to  aU 
other  antigonorrhoica,  as  it  is  absolutely  harmless  and  really  antiseptic. 

1  Barlow,  Miinch.  Med.  Woch.,  1897,  Nos.  45  and  46. 


286  GONOREHEA 

They  also  claim  for  it  a  curative  action  similar  to  that  of  silver  nitrate, 
without  producing  the  same  amount  of  irritation. 

It  is  a  fine  yellow  powder  which  is  easily  soluble  in  water.  It  is  an 
intimate  and  very  stable  compound  of  silver  and  a  protein. 

Like  all  the  other  silver  albuminates,  solutions  of  protargol  do  not  pre- 
cipitate albumin,  and  are  not  precipitated  by  common  salt;  they  are  there- 
fore, theoretically  at  any  rate,  capable  of  acting  on  the  gonococci  which 
are  deeply  located  within  the  epithehum. 

Protargol  contains  8-3  per  cent,  silver,  and  is  used  for  irrigations  in  the 
dose  of  1 :  2,000  or  1 :  1,000  (Barlow).  According  to  Wossidlo,  protargol  is 
much  more  irritating  than  albargin. 

Argyrol,  another  organic  silver  salt,  was  discovered  by  Barnes  of  Phila- 
delphia, in  1902,  and  has  been  chiefly  advocated  by  Swinburne^  and  De  Sard,^ 
who  claims  it  to  be  superior  to  any  other  known  urethral  antiseptic.  It 
contains  30  per  cent,  silver,  does  not  coagulate  albumin,  is  not  caustic,  and 
produces  no  inflammatory  reaction  in  the  urethra. 

According  to  De  Sard,  histological  examinations  show  that  in  cases 
treated  with  argyrol  irrigations  the  epithehum  is  almost  completely  deprived 
of  its  epithelial  cells.  Moreover,  argyrol  causes  no  pain,  and  has  a  sooth- 
ing effect  during  the  acute  stage,  doing  away  with  all  sharp  pain.  In  the 
beginning  1  or  0-5  per  cent,  solutions  may  be  used. 

The  chief  advantages  of  argyrol  are,  thus,  that  it  is  well  borne,  and  that 
it  is  to  a  certain  extent  analgesic,  even  in  the  acute  stage.  It  is,  however, 
not  always  harmless,  as  Janet ^  has  pointed  out.  Its  repeated  use  in  strong 
doses  may  be  followed  by  changes  in  the  urethral  epithehum  which  are  not 
without  importance  for  its  future.  Janet  therefore  advises  relatively  weak 
solutions,  such  as  2: 1,000  and  4: 1,000,  for  irrigations,  and  follows  them  up 
by  an  injection  of  a  5  to  20  per  cent,  solution  given  with  a  syringe.  He 
always  administers  two  irrigations,  followed  by  injections,  per  day  during 
the  first  half-week.  He  gives  one  irrigation  on  the  following  two  to  six 
days,  and  in  favourable  cases  all  is  over  in  five  to  seven  days. 

Janet  holds  that  argyrol  is  a  very  powerful  remedy  in  the  initial  stage, 
as  long  as  the  gonococci  are  on  the  surface.  When  the  disease  is  confirmed 
— i.e.,  after  the  gonococci  have  penetrated  into  the  substance  of  the  mucous 
membrane  and  into  the  urethral  glands— its  value  is  hmited.  He  then 
discards  it,  and  continues  the  treatment  with  permanganate  irrigations. 
Another  drawback  of  argyrol  is  its  expense. 

Argentamin  is  an  organic  silver  gait  which  has  been  used  by  Schaffer 
in  the  dose  of  1 : 2,000  to  1 : 1,000,  and  appears  to  have  an  energetic  bacteri- 
cidal action. 

1  Swinburne,  Medical  Record,  October  11,  1902. 

2  De  Sard,  Presse  Medicale,  February  13,  1909. 

3  Janet,  Ass.  Fran^.  d'UroL,  1910,  p.  263. 


THE  TKEATMENT  OF  ACUTE  GONORRHEA      287 

Argonin  belongs  to  the  same  class,  and  contains  4  per  cent,  of  silver. 
It  has  been  used  by  Zydlowitz  and  Lewin,  and  also  by  Jadassohn  in  7 '5  per 
cent,  solution  for  instillations,  and  in  1 :  4,000  solution  for  irrigations.  Follen 
Cabot,  of  New  York,  speaks  highly  of  it. 

Silver  citrate,  or  itrol,  has,  according  to  Werler,^  a  very  marked  bacteri- 
cidal action,  and  is  superior  to  all  other  antigonorrhoica  known.  He  uses 
it  in  solutions  of  1 : 1,000  to  1 : 4,000.  He  claims  for  it  a  very  marked  pene- 
trating power  and  a  strong  antiseptic  action  within  the  mucosa. 

Ichthargan  has  been  highly  recommended  by  Lohnstein.  This  com- 
pound contains  30  per  cent,  silver,  and  is  used  for  irrigations  in  a  dilution 
of  1 :  4,000  to  1 :  1,000.  For  instillations  it  should  be  used  in  a  strength  of 
0-5  to  5  per  cent.^ 

Largin  is  a  greyish  powder  containing  11  per  cent,  of  silver,  which  is 
soluble  in  water,  glycerine,  and  blood-serum.  Its  aqueous  solutions  are 
clear,  slightly  alkaline,  and  very  stable.  Chemically  it  is  closely  allied  to 
protargol,  and  shares  all  its  qualities,  but  it  has  a  much  more  potent  bacteri- 
cidal action.  Stark  ^  has  successfully  employed  solutions  varying  in  strength 
from  1 :  400  to  1 :  100.     For  instillations  1 :  200  to  1 :  50  may  be  used. 

The  experiments  quoted  by  Wossidlo  give  some  information  as  to  the 
relative  penetrating  powers  of  these  various  compounds. 

Schaif  er  took  pieces  of  rabbit  liver,  and  left  them  for  ten  hours  in  contact 
with  solutions  of  silver  nitrate  (1:  2,000)  and  argentamin  of  corresponding 
strengths.  They  were  then  put  into  a  solution  of  ammonium  sulphide, 
which  precipitated  the  silver  as  a  brownish  mass  wherever  it  was  present. 
In  this  way  he  was  able  to  demonstrate  the  penetration  of  argentamin  to  be 
three  times  greater  than  that  of  silver  nitrate. 

Pezzoli  made  similar  experiments  with  human  hver,  impregnating  the 
pieces  with  silver  nitrate,  argentamin,  protargol,  and  largin,  respectively. 
He  found  that,  whilst  the  penetrating  power  of  argentamin  was  100  milh- 
metres,  those  of  silver  nitrate,  largin,  and  protargol,  were  65,  58  and  38 
millimetres  respectively. 

Benario  has  also  carried  out  some  interesting  researches  on  the  penetra- 
tion power  of  protargol.  He  took  agar  tubes,  which  he  inoculated  with 
bacterial  cultures;  he  then  poured  a  little  0'5  per  cent,  protargol  solution 
into  them  and  incubated  them.  On  the  following  days  he  noted  that  growth 
had  only  taken  place  12  to  13  milhmetres  below  the  surface  of  the  agar. 
The  protargol  had  thus  penetrated  to  that  depth,  and  checked  all  growth 
where  it  was  present. 

^  Werler,  Derm.  Zeits.,  1897,  vol.  iii.,  Nos.  5  and  6. 

-  PaulRychner,  "Traitement  de  I'Uretrite  Blennorragique  par  I'lchthargan,"  Ann. 
Genito-Urin.,  1903,  p.  1281. 

3  Stark,  Monatsch.  J.  Pract.  Derm.,  1899,  vol.  xxviii.,  p.  165. 


288  GONORKHEA 

Pezzoli  undertook  interesting  researches  of  a  similar  character  which 
have  since  been  confirmed  by  Kamen. 

Glass  tubes  of  equal  size  were  filled  up  to  a  height  of  5  centimetres  with 
sterilized  gelatin,  and  each  of  these  tubes  was  subsequently  inoculated  with 
a  drop  of  a  broth  culture  containing  Bacillus  coli.  T  he  tubes  were  well  shaken 
in  order  to  spread  the  bacilli  evenly,  and  then  the  gelatin  was  allowed  to  set. 
The  tubes  were  then  filled  with  different  silver  solutions  to  a  level  of  12  centi- 
metres, and  placed  in  an  incubator,  where  they  were  protected  against  light. 

After  three  or  four  days  one  found  that  growth  had  taken  place  in  every 
tube,  but  that  they  all  showed  a  sterile  zone  which  varied  in  extent  with 
the  silver  salt  used— 16  millimetres  with  argentamin,  4  millimetres  with 
silver  nitrate,  10  millimetres  with  largin,  and  5  millimetres  with  protargol. 

The  penetration  power  of  these  organic  salts  of  silver  is  definitely  proved 
by  these  experiments ;  but  in  practice — as  has  been  pointed  out  by  Finger — 
this  penetration  power  is  insufficient.  There  are,  according  to  him,  always 
cocci  left  within  the  mucosa  and  the  glands,  which  these  silver  salts  fail  to 
affect. 

Corrosive  sublimate  is  an  excellent  drug  for  cases  in  which  the  microscope 
has  shown  that  only  the  ordinary  adventitious  organisms  are  present.  It 
should  only  be  used  in  high  dilutions — 1 :  10,000  or  1 :  20,000 — and  the  solu- 
tions should  not  contain  any  tartaric  acid  or  spirit. 

The  curative  effect  of  irrigations  with  perchloride  of  mercury  is  abso- 
lutely remarkable,  when  only  ordinary  organisms  are  present.  They  dis- 
appear after  four  to  five  irrigations,  as  a  rule. 

But  even  these  very  weak  solutions  are  sometimes  painful,  and  therefore 
their  use  is  somewhat  limited,  and  a  certain  amount  of  caution  is  required. 
The  drug  has  no  specific  action  on  the  gonococcus. 

Oxycyanide  of  mercury  has  almost  the  same  properties  as  the  perchloride, 
but  it  is  free  from  its  drawbacks.  It  can  be  used  in  much  bigger  doses,  and 
seldom  gives  rise  to  any  pain.  Solutions  varying  between  1 :  4,000  and 
1 : 1,000  are  generally  used;  it  is  also  void  of  any  special  action  on  the  gono- 
coccus. 

It  is  indispensable  to  be  acquainted  with  some  of  the  peculiarities  of 
this  salt.  Even  in  small  doses  it  occasionally  gives  rise  to  pain  in  some 
patients,  whilst  others  experience  no  inconvenience  with  much  larger  doses. 

This  phenomenon  seems  to  depend  on  the  presence  of  iodine  in  the  body, 
and  therefore  it  is  always  advisable  to  ask  the  patient  if  he  has  been  taking 
potassium  iodide  or  any  other  iodine  preparation  lately.  If  the  answer  is 
in  the  affirmative,  the  oxycyanide  should  on  no  account  be  used. 

The  presence  of  iodides  in  the  circulation  leads  to  a  decomposition  of 
the  salt  within  the  bladder.  Iodide  of  mercury  is  formed  within  the  vesical 
mucous  membrane,  and  this  chemical  reaction  often  produces  intense  pain. 


THE  TREATMENT  OF  ACUTE  GONORRHEA      289 

Cyanide  of  mercury  has  been  advocated  by  Escat  for  gonorrheal  dis- 
charge. This  drug  is  supposed  to  cause  a  considerable  sero-hematous  ex- 
udation, which  renders  the  soil  inapt  for  the  growth  of  the  gonococci. 

It  is  not  quite  so  toxic  as  one  would  think  at  first  sight.  Both  bladder 
and  urethra  tolerate  5  :  1,000  solutions  without  inconvenience. 

Escat  ranks  this  salt  first  amongst  the  antigonorrhoica ;  its  antiseptic 
properties  are  considerable,  the  mucous  surface  tolerates  it  well  and  reacts 
to  it  in  a  special  manner.  Moreover,  it  does  not  coagulate  albumin  like 
the  perchloride. 

Escat  uses  for  abortive  treatment  2  to  5  per  mille  solutions.  One 
usually  begins  with  a  dilution  of  0*5  or  1  gramme  per  1,000.^ 

Collargol. — Dr.  Uteau^  has  recommended  the  use  of  collargol  for  irriga- 
tions in  gonorrheal  urethritis.  These  irrigations  are  said  to  have  the  great 
advantage  of  being  painless  even  during  the  acute  stage;  they  can  therefore 
be  used  as  preparatory  treatment,  even  if  they  are  not  curative. 

Salicylic  acid  may  be  used  in  dilutions  of  1 :  3,000  or  1 :  2,000. 

Sodium  salicylate  has  been  used  with  success  by  Malecot. 

Hydrogen  ^peroxide,  tried  by  Castan  of  Beziers,  has  given  no  result  in 
his  hands. 

Picric  acid,  according  to  the  same  author,  has  no  definite  action  on 
the  gonococcus.  It  is,  however,  not  useless  in  the  treatment  of  chronic 
cases. 

Citrate  of  bismuth,  used  by  Baker  and  Leroy^  towards  the  decUne  of 
gonorrhea,  gives  good  results,  but  no  better  ones  than  those  obtained  with 
permanganate.  These  authors  use  a  1 :  2,000  solution  to  begin  with,  and 
rapidly  increase  the  strength  to  1 :  500. 

Nitric  Acid. — Dr.  Porosz  of  Budapest  thought  that  the  action  of  silver 
nitrate  was  mainly  due  to  its  nitric  radical,  and  therefore  recommended 
the  use  of  nitric  acid.  He  irrigates  the  urethra  with  solutions  of  nitric  acid 
in  a  dilution  of  1 :  3,000  to  1 :  1,000. 

The  use  of  Thallin  has  been  advocated  by  Casper  for  treating  gonorrhea."* 

2.  Urethral  Injections. — Urethral  injections  are  given  by  means  of  a 
syringe  or  a  rubber  ball  for  the  purpose  of  introducing  a  modifying  liquid 
into  the  urethra. 

Advantages. — This  treatment  is  very  simple,  and  appeals  to  the  patients, 
hence  the  favour  which  it  enjoys  even  nowadays.  The  number  of  drugs 
used  for  these  injections  is  simply  enormous. 

1  Escat,  C.  R.  del' Ass.  Frang.  d'UroL,  1898,  p.  182, 

2  Uteau,  "  Traitement  des  Blennorragies  par  les  grands  Lavages  Uretro-Vesicaux  au 
Collargol,"  Eev.  Prat,  des  Mai.  des  Organ.  Oenito-Urin.,  Lille,  1909-10,  vol.  vi.,  p.  41. 

3  Balzer  et  Leroy,  Presse  Medicale,  October  3,  1900. 

4  Casper,  Berl.  Klin.  Woch.,  1900,  No.  22,  p.  482. 

19 


290 


GONORRHEA 


Drawbacks. — Generally  speaking,  the  drawbacks  overweigh  the  ad- 
vantages. 

In  the  vast  majority  of  cases  the  injections  are  badly  done,  and  lead  to 
complications  sooner  or  later.  They  often  give  rise  to  prostatitis,  cystitis, 
vesiculitis,  and  orchitis,  and  almost  invariably  set  up  a  littritis. 

Technique. — In  order  to  avoid  these  accidents  the  patients  have  to  take 
certain  precautions.  Firstly,  they  should  not  be  given  any  syringes  which 
hold  more  than  5  or  6  c.c.  (maximum).  Secondly,  they  should  make  water 
before  using  the  injection,  in  order  to  free  the  canal  from  any  secretions 
which  may  have  accumulated  in  it.  Thirdly,  they  should  cleanse  the  glans 
and  the  meatus  and  wash  the  anterior  urethra  once  or  twice  with  the  syringe, 
allowing  the  fluid  to  run  out  immediately.  After  these  prehminaries  the 
injections  proper  begin.  The  patient  injects  again  the  contents  slowly,  and 
closes  the  meatus  with  his  fingers.  The  fluid  is  thus  retained  for  five 
minutes  or  so,  and  then  allowed  to  escape;  this  process  is  repeated  a  few 
times,  and  the  patient  tries  to  make  water  as  seldom  as  possible  in  the 
intervals. 

Indications. — The  use  of  injections  is  rarely  indicated.  One  should  be 
especially  reluctant  to  prescribe  them  in  cases  of  acute  gonorrhea,  as  they 
are  then  almost  certain  to  lead  to  complications. 

Their  use  is  least  unjustifiable  immediately  after  dilatation  treatment, 
once  the  latter  has  produced  its  full  effect — i.e.,  they  are  hardly  ever  indi- 
cated except  in  chronic  gonorrhea. 

Substances  used  for  Injections.- — ^The  most  active  and  most  recommend- 
able  drugs  for  this  purpose  are  the  silver  salts,  amongst  which  the  following 
may  be  used  with  advantage : 

1.  Silver  nitrate  in  a  1:  1,000  solution,  which  is  well  borne;  the  strength 
may  be  raised  to  1 :  500. 

2.  Protargol. — To  be  used  in  various  doses;  for  instance,  one  may  pre- 
scribe a  treatment  lasting  three  weeks,  a  1:  300  solution  being  injected  on 
the  first  seven  days  thrice  daily ;  during  the  next  week  a  1 :  200  solution  is 
used,  and  then  a  1 :  100  solution.  Protargol  always  brings  on  a  fairly  well 
marked  inflammatory  reaction  of  the  urethral  mucosa,  and  therefore  its  dose 
must  be  graduated  according  to  each  individual  case. 

Ahlstroem  has  used  4  per  cent,  solutions. 

From  the  lengthy  hst  of  prescriptions  for  injections  a  few  of  the  most 
important  ones  may  be  quoted  here: 


Ricord's  Injecti 


Zinc  sulphate 
Lead  acetate 
Water 


1  gramme. 

2  grammes. 
200  c.c. 


THE  TREATMENT  OF  ACUTE  GONORRHEA      291 


The  ''Three 

Sulphates  "  Irij 

'ection. 

Zinc  sulphate    ,  . 

0-5  gramme. 

Copper  sulphate 

..      0-5 

Iron  sulphate    . . 

. .      0-5 

Water 

•• 

200  grammes 

e  of  iron  was  used 

in  1%  solution,  and  amongst  the  ot; 

Sulphate  of  copper 

in  \-2% 

solution. 

Sulphate  of  zinc 

„    0-2- 

1%          ,, 

Tannin 

,.     1% 

5> 

Alum 

»     1% 

5J 

Lead  acetate 

„     1% 

,, 

Claret  diluted,  with  two  or 

three  parts 

of  water. 

Bismuth  subnitrate 

used  in 

I  2-5%      suspension. 

Resorcin 

j> 

1-4% 

solution. 

Quinine  sulphate 

„ 

0-5-1% 

Argentamin 

0-5-1% 

Largin 

, 

0-25-1% 

Albargin 

, 

0-25-1% 

Itrol 

» 

0-25-0-5% 

Ichthargan 

, 

2% 

Novargan 

, 

, 

0-25-0-5% 

Ichthyol 

, 

, 

1-5% 

Thallin 

5 

2% 

Hydrogen  peroxide 

, 

3% 

Picric  acid  has  been  used  by  Brun  of  Beyrouth  in  0*5  and  1  per  cent, 
doses.  His  patients  have  to  inject  5  to  6  c.c.  into  the  closed  meatus,  and 
to  leave  the  fluid  in  the  urethra  for  three  minutes;  these  injections  are  re- 
peated two  or  three  times  per  day. 

Hermophenyl  has  been  used  by  Boudin  in  the  treatment  of  gonorrhea. 
A  1 :  250  aqueous  solution  is  injected  by  the  patient  six  times  per  day. 

Wolbarst  recommends  thallin,  which  does  not  irritate,  and  soon  checks 
the  inflammation. 

Airol. — ^Legeu  and  Levi  in  France,  Merlin  in  Germany,  Vignolo-Lutati, 
and  Benassi,  have  recommended  the  use  of  airol  for  injections  in  acute 
gonorrhea.     Its  action  seems  doubtful;  it  is  used  in  1  per  cent,  solution. 

Vignolo  and  Benassi  prescribe  as  follows: 

Airol    . .  . .  . .  . .  . .     25  grammes. 

Glycerine  . .  . .  . .  . .    100         „ 

Collargol  has  been  used  in  1 :  1,000  dilution  by  Tansard. 

Citrate  of  bismuth  has  been  tried  by  Balzer  and  Leroy  in  solutions  of 
1:  1,000  to  1:500. 

Argyrol  has  been  advocated  by  De  Sard,  who  gives  an  injection  of  10  c.c. 
of  a  10  per  cent,  solution  into  the  anterior  urethra,  which  is  retained  for 
five  to  ten  minutes. 


292 


GONOEEHEA 


Kervin^  recommends  a  20  per  cent,  solution,  of  which  7  c.c.  are  injected 
into  the  anterior  urethra  and  retained  ten  minutes. 

Some  other  formulae,  such  as  the  following,  have  also  been  used: 

Suspended  calomel 

,,  iodoform 

„  bismuth  subnitrate 

Distilled  water 


or- 


1 

gramme. 

5 

grammes 

5 

»» 

100 

" 

5 

grammes 

5 

,, 

4 

- ,, 

4 

,, 

100 

J, 

Suspended  dermatol 
„  airol 

„  xeroform 

„  thioform 

Distilled  water 


;^ilQ — Jungano^  has  studied  the  action  of  bile  upon  the  gonococcus,  and 
found,  as  Neufeld  did  in  the  case  of  other  organisms,  that  it  has  a  definite 
antigonococcal  action.  He  then  discovered  that  a  10  per  cent,  solution  of 
sodium*  cholate  had  similar  properties.  He  finally  experimented  with  a 
1  per  cent,  solution  of  sodium  cholate  on  human  beings,  and  obtained  a 
decided  improvement  in  each  case. 

3.  The  Balsam  Preparations. — The  balsam  preparations  are  adminis- 
tered by  the  mouth,  and  have  the  property  of  diminishing,  if  not  of  stopping 
altogether,  the  pathological  secretions  of  the  urethra.  They  were  far  more 
widely  used  formerly  than  nowadays,  and  one  can  easily  understand  that 
they  should  have  met  with  much  favour.  To  cure  one's  gonorrhea  by 
taking  a  drug  is  so  easy  and  so  simple  that  the  pubhc  were  bound  to  turn 
their  attention  to  them.  Unfortunately,  their  action  is  not  constant,  and 
in  some  cases  they  do  harm.  It  is  quite  true  that  they  dry  up  the  secre- 
tions, but  they  do  not  kill  the  gonococcus ;  they  are  therefore  apt  to  mislead 
the  patient,  who  sees  his  discharge  diminishing  under  their  influence,  and 
then  considers  himself  safe.  He  gives  up  all  treatment,  and  allows  his 
gonorrhea  to  continue  its  torpid  course.  In  a  great  number  of  instances 
the  patients  were  so  convinced  of  having  been  cured  by  the  use  of  balsam 
preparations  that  they  married  and  infected  their  wives.  Others  developed 
a  stricture  ten  to  twenty  years  later  in  their  urethra,  to  their  great  astonish- 
ment. "  I  certainly  was  cured  of  my  gonorrhea;  fori  had  taken  balsams 
for  a  very  long  time,"  is  a  statement  which  one  often  hears. 

It  is  certain  that  the  balsam  preparations  are  most  important  drugs  for 
the  treatment  of  certain  conditions,  and  should  not  be  withheld  in  certain 
cases  (see  Cystitis,  Chapter  IX.). 

The  best-known  balsam  preparations  are  cubebs,  copaiba,  and  sandal- 


^  Kervin,  Medical  Record,  June  6,  1903. 

2  Jungano,  Ass.  Frang.  d' Tirol.,  1909,  p.  261. 


THE  TREATMENT  OF  ACUTE  GONORRHEA      293 

wood-oil;  others  which  have  a  less  specific  action  are  balsam  of  Tolu,  Peru 
balsam,  Canada  balsam,  and  kawa-kawa. 

Copaiba. — Copaiba  is  a  transparent,  oily,  amber-coloured  hquid  of  a 
pecuhar  and  disagreeable  odour  with  a  persistent  bitter  taste.  It  has  been 
in  use  for  two  centuries. 

It  is  the  resin  derived  from  a  tree  of  the  Copaifera  species,  which  grows 
in  South  America,  Mexico,  and  Brazil,  and  is  collected  in  the  summer  by 
incising  the  trunk  of  the  trees. 

Dose.— In  order  to  obtain  any  effect,  8  to  12  grammes  should  be  taken 
within  twenty- four  hours.  Chopart's  famous  prescription,  which  is  a 
masterpiece  in  its  way  owing  to  its  unsurpassed  nauseating  taste, 
consisted  of — 


Syrup  of  copaiba 
Rectified  alcoliol 
SjTup  of  Tolu  . . 
Peppermint-water 
Nitric  alcohol  . . 


50  grammes. 

50 

50 

100 

5 


Three  to  six  tablespoons  were  to  be  taken  every  day.  This  mixture  often 
led  the  stomach  to  protest,  and  inspired  the  patients  with  a  feehng  of  disgust 
and  revolt. 

It  is  usual  to  prescribe  copaiba  in  gelatin  capsules  containing  1  gramme 
each  (10  minims  in  this  country — A.  F.). 

Balsam  of  copaiba  is  given  in  doses  of  4  to  5  grammes  per  day;  one  can 
also  prescribe  the  resin  or  sodium  copaivate. 

Action. — The  antigonorrheal  action  of  copaiba  is  indirect,  and  takes 
place  only  through  the  urine.  It  does  not  affect  the  gonococcus  directly, 
and  unless  the  urine  containing  the  active  principles  of  the  balsam 
comes  into  direct  contact  with  the  diseased  surfaces  no  therapeutic  effect 
is  noted. 

Ricord  in  1849,  and  Roquette  in  1854,  have  shown  that  the  active 
principles  of  copaiba  pass  into  the  urine  and  are  thus  brought  into  contact 
with  the  urethra.  The  drug  therefore  exerts  its  action  locally,  and  modijS.es 
the  urethritis  favourably.  Two  patients  who  suffered  from  urethral 
fistulse,  were  treated  for  a  urethritis  by  giving  them  balsam  of  copaiba  in- 
ternally. The  part  of  the  urethra  behind  the  fistula,  which  was  frequently 
irrigated  by  the  urine,  healed  under  its  influence,  whilst  the  part  in  front 
remained  inflamed  until  it  was  treated  by  injecting  it  with  the  urine  of  the 
patient. 

Ricord  also  administered  copaiba  to  a  patient  who  was  free  from  gonor- 
rhea, and  used  this  patient's  urine  successfully  for  injections  into  patients 
who  were  suffering  from  gonorrhea  (Finger). 

It  follows  from  these  facts  that,  in  order  to  obtain  the  maximum  effect 


294  GONOERHEA 

from  balsam  preparations,  the  patients  should  take  as  little  fluid  as  possible. 
Their  urine  is  then  less  in  amount,  and  the  drug  is  present  in  it  in  a  higher 
concentration.  It  is  also  advisable  that  the  patients  should  make  water  fre- 
quently, in  order  to  renew  the  curative  action  of  their  urine.  Moreover,  one  of 
the  chief  conditions  of  success  with  balsam  therapy  is  its  prolonged  use — i.e., 
the  administration  should  be  continued  at  least  eight  days  beyond  the 
disappearance  of  all  oozing  from  the  urethra,  and  then  it  should  not  be  left 
off  suddenly,  but  the  doses  should  be  diminished  gradually. 

Very  often  copaiba  upsets  the  alimentary  canal;  nausea,  vomiting,  cohc, 
and  diarrhea,  are  common  after  its  use.  The  urine  acquires  a  special  odour, 
which  is  noticeable  about  two  hours  after  the  drug  has  been  taken.  It 
sometimes  irritates  the  kidneys,  and  a  little  albuminuria  or  hematuria  may 
be  observed,  in  which  case  the  use  of  the  drug  should  be  discontinued.  The 
skin  and  the  sweat  also  acquire  a  pecuhar  odour.  A  roseolar  rash  afiecting 
chiefly  the  wrists,  ankles,  knees,  hands,  and  feet,  and  accompanied  by  fever, 
is  also  occasionally  noted. 

The  administration  of  copaiba  is  thus  not  free  from  objections.  The 
drug  is  digested  only  with  difiiculty,  and  gives  rise  to  indigestion.  Rashes 
are  common,  such  as  erythemata,  sometimes  papular  in  character,  roseola, 
or  urticaria,  or  purpura,  and  small  macules  which  may  be  cir- 
cumscribed or  confluent,  and  vary  in  colour  from  a  violet  to  a  red. 
All  these  ill- effects  cease  immediately  as  soon  as  the  use  of  the  drug  is  dis- 
continued. 

Cubebs. — This  substance,  which  is  collected  in  Java  and  in  Sumatra,  has 
been  known  for  more  than  a  century.  It  is  the  small,  spherical,  brown  or 
blackish  fruit  of  Piper  cubeba,  and  is  less  irritant  than  copaiba,  but  in- 
ferior in  its  action.  Cubebs  has  been  chiefly  recommended  in  the  form  of  a 
powder,  because  it  is  free  in  this  form  from  the  ill- effects  of  copaiba,  and  is 
less  dangerous.  It  can  also  be  given  in  cachets  or  in  the  shape  of  ethereal  or 
of  ethereal  hydro- alcoholic  extracts. ■■■  According  to  Guiard,  a  dose  of  2  to  6 
grammes  per  day  is  required  in  order  to  obtain  any  effect.  He  gives  this 
drug  for  three  weeks  in  the  following  way:  During  the  first  week  twelve 
capsules  per  day,  which  contain  each  0'5  gramme  of  the  ethereal  hydro- 
alcohoHc  extract,  during  the  second  week  ten  capsules  per  day,  and  during 
the  third  week  eight  capsules.  This  treatment  should  be  continued  unin- 
terruptedly up  to  the  end,  even  if  the  first  doses  appear  to  have  accom- 
plished a  cure. 

The  balsam  preparation  most  commonly  employed  in  France  is  the 
opiate,  which  is  a  mixture  containing  copaiba  and  cubebs  in  variable  pro- 
portions. 

^  The  B.P.  preparations  are  an  oil,  dose  5  to  20  minims,  and  a  tincture,  dose  ^  to 
1  drachm  (A.  F.). 


THE  TREATMENT  OF  ACUTE  GONORRHEA      295 

One  of  the  most-used  formulae  is  the  following: 


Copaiba 

Cubebs 

Powdered  cachou 

Essence  of  peppermint    . . 

Essence  of  canella  (wild-cinnamon) 


30  grammes. 
40 

5 

5  drops. 


This  opiate  is  taken  in  the  form  of  little  balls,  of  the  size  of  a  hazelnut, 
six  to  eight  per  day  in  unleavened  bread.  This  dose  is  reached  gradually, 
and  after  eight  to  fourteen  days  one  reduces  the  dose  daily  by  one  boulette, 
until  finally  no  more  are  taken. 

Some  patients  object  to  the  opiate.  It  sometimes  causes  irritation  of 
the  ahmentary  canal;  colic,  diarrhea,  vomiting,  and  retching,  are  not  un- 
common after  its  use.  It  is  therefore  better,  in  the  case  of  private  patients, 
to  prescribe  according  to  one  of  the  following  formulae: 

Powdered  cubebs              . .  . .  . .  . .  10  grammes. 

Copaiba               . .              . .  . .  . .  . .  3        „ 

Tar  syrup           . .              . .  . .  . .  . .  q.s.  to  bind. 

or — 

Copaiba               . .              . .  . .  . .  . .  10  grammes. 

Cubebs               ..             ..  ..  ..  ..  20        „ 

Tartrate  of  iron  and  potash  . .  . .  . .  2         „ 

Syrup  of  krameria  (rhatany)  . .  . .  . .  q.s. 

Sandalwood-Oil. — This  substance  comes  from  Oceania,  Southern  Asia, 
and  East  Africa. 

Its  action  is  at  least  equal  to  that  of  copaiba,  and  is  infinitely  less  irrita- 
ting to  the  alimentary  canal.  Its  administration  is,  however,  often  followed 
by  pain  in  the  loin  and  symptoms  of  renal  congestion.  It  is  a  clear  yellow 
essence  obtained  by  distilling  sandalwood.  It  is  prescribed  in  doses  from 
1  to  8  or  10  grammes  per  day,  put  up  in  capsules  of  0'25  or  0*5  gramme. 
The  average  daily  dose  is  3  grammes. 

Santalol  B.,  or  Eumictin. — This  drug  is  better  tolerated  than  the  ordinary 
preparation.  It  is  given  in  0-25  gramme  capsules  in  a  dose  of  1  to  2 
grammes  per  day. 

Arrheol. — This  preparation  is  one  of  the  active  principles  of  sandalwood- 
oil,  and  has  the  same  therapeutic  action.  It  has  the  advantage  of  being 
a  definite  chemical  compound,  and  of  being  more  active  than  the  essential 
oil  if  equal  weights  be  given.  It  is  administered  in  0"2  gramme  capsules, 
of  which  six  to  twelve  per  day  are  given. 

Its  analgesic  action  is  well  marked,  and  it  causes  no  renal  or  digestive 
disturbances. 

Lihanol  has  been  advocated  by  Professor  Gemy  of  Algiers  for  the  treat- 


296  GONOEEHBA 

ment  of  gonorrhea.  It  is  best  given  in  capsules  containing  0-25  or 
0-3  gramme.     The  daily  dose  varies  from  3  to  8  grammes. 

It  never  affects  the  kidneys  and  the  alimentary  canal. ^ 

Buchu  appears  to  act  as  a  diuretic  and  as  a  modifier  of  the  urethral 
mucous  membrane.  The  tincture  is  the  best  preparation,  as  it  contains  all 
the  active  principles  of  the  plant. 

Tincture  of  buchu  ^  can  either  be  prescribed  by  itself  with  pure  water, 
or  in  a  diuretic  infusion  (uva  ursi,  etc.).  The  average  dose  for  two  days  is 
20  to  60  drops. 

Fluid  Extract  of  Kawa-Kawa. — M.  Abramovitch  recommends  the  use  of 
the  fluid  extract  of  kawa-kawa.  This  plant,  which  grows  in  the  Pacific 
Islands,  is  gifted  with  antigonorrheal  properties. 

The  extract  of  kawa-kawa  is  administered  three  times  per  day  in  doses 
of  20  to  40  drops. 

It  is  completely  inoffensive,  and  in  this  respect  it  is  superior  to  the  other 
balsams.^ 

Gonosan. — This  is  a  resin  extracted  from  the  kawa-kawa  plant. 
It  is  a  greenish-yellow,  transparent,  oily  liquid  which  is  soluble  in 
alcohol,  ether,  and  chloroform,  and  has  an  aromatic  odour.  Its  use  is 
said  to  obviate  the  drawbacks  of  balsam  treatment  (pain  on  making 
water,  dyspepsia,  etc.).  Six  to  nine  capsules,  containing  0*5  gramme,  are 
given  daily. 

This  drug  contains  20  per  cent,  of  sandalwood. 

Salol  appears  to  be  useless  in  the  treatment  of  gonorrhea.  It  is  often 
given  together  with  santal — "  salol-santal,"  which  contains  33  per  cent, 
of  salol. 

Arhovin,  Thyresol,  Santyl,  are  other  German  "  antigonorrhoica "  of 
similar  composition.^ 

Method   of  Administering  the  Balsam  Preparations. 

The  balsam  preparations  were  formerly  only  prescribed  in  the  treatment 
of  gonorrhea  when  all  the  congestive  symptoms  had  disappeared;  they 
were  therefore  usually  given  about  the  beginning  of  the  fifth  week.  An 
indispensable  precaution  consisted  in  always  ascertaining  that  the  patients 
were  free  from  albuminuria.  Large  doses  were  given  for  fifteen  days  to 
three  weeks. 

1  Gemy,  Presse  Medicate,  November  29,  1902,  p.  1150. 

2  Martinet,  Presse  Medicate,  January  4,  1902,  p.  20. 

3  I  believe  kawa-kawa  to  be  absolutely  useless,  and  have  never  seen  any  benefit 
from  gonosan  (A.  F.). 

*  They  are  all  equally  useful  and  useless  according  to  the  point  of  view  which  one 
takes  (A.  F.). 


THE  TREATMENT  OF  ACUTE  GONORRHEA      297 

4.  The  Treatment  of  Acute  Gonorrhea  by  Bier's  Method.— Dr.  Miles 
of  Edinburgh  has  recommended  the  use  of  Bier's  treatment  for  acute 
gonorrheal  urethritis,  and  has  given  an  account  of  300  cases  treated  in 
this  way.^ 

He  uses  a  glass  cyhnder,  fitted  at  its  open  end  with  a  rubber  diaphragm 
which  adapts  itself  accurately  to  the  root  of  the  penis.  By  means  of  a 
small  pump  a  vacuum  is  made  in  the  cylinder,  which  is  18  centimetres  long 
and  5  centimetres  in  diameter. 

After  the  patient  has  emptied  his  bladder,  the  apparatus  is  applied  and 
a  partial  vacuum  is  made.  The  penis  becomes  immediately  congested,  and 
a  few  drops  of  pus  appear  at  the  meatus.  After  ten  to  fifteen  minutes  air 
is  allowed  to  enter  the  cylinder.  One  lets  the  patient  rest  for  five  minutes, 
and  then  makes  another  similar  application,  which  again  lasts  ten  minutes 
or  so.  This  process  is  repeated  three  times  at  each  visit,  which  therefore 
lasts  about  an  hour.  This  treatment,  which  should  not  give  rise  to  any 
pain,  is  carried  out  once  in  twenty-four  hours,  and  in  mild  cases  applications 
lasting  twenty  minutes  are  sufficient. 

If  one  examines  the  pus  before  and  after  each  congestion  treatment, 
one  finds  some  interesting  changes,  which  are  remarkably  regular  and  con- 
stant. The  number  of  polymorpho-nuclear  leucocytes  is  increased,  and 
they  contain  a  larger  number  of  gonococci.  In  one  instance.  Miles  noted 
an  enormous  number  of  extracellular  cocci  before  the  treatment.  After 
the  application  of  the  suction,  there  were  fewer  organisms,  and  they  were 
nearly  aU  intracellular. 

The  therapeutic  results  are  very  satisfactory.  One  visit  is  sufficient  to 
diminish  the  pain  and  the  dysuria  considerably,  and  after  two  visits  these 
symptoms  have  disappeared  completely.  If  the  case  be  treated  early,  the 
discharge  dries  up  within  a  fortnight,  a  slight  moisture  being  perhaps  left 
for  another  week.  In  some  patients  the  discharge  disappeared  after  three 
to  four  visits.  Others  only  got  well  after  three  to  four  weeks.  Noteworthy  is 
the  almost  complete  absence  of  comphcations  in  patients  who  are  treated 
by  Bier's  method.  There  were  only  two  cases  of  epididymitis  amongst 
Miles' s  material;  the  posterior  urethra  was  hardly  ever  affected;  prostatitis, 
prostatic  abscess,  cystitis,  and  peri- urethral  abscess,  were  never  noted. 
However,  mixed  infections  and  buboes  were  observed  twice,  and  two  other 
cases  developed  gonorrheal  rheumatism. 

Bier's  method  is  not  apphcable  to  chronic  cases.  In  "  gleet " 
(chronic  gonorrhea)  it  increases  the  discharge  and  brings  on  pain  and 
dysuria. 

The  advantages  of  this  congestion  treatment  are  its  simplicity  and  its 

1  Miles,  Med.-Chirurg.  Society,  Edinburgh,  May  4,  1910. 


298  GONORRHEA 

cleanliness.  Moreover,  the  patients  can  treat  themselves,  and  it  is  most 
useful  when  injections  cannot  be  given — for  instance,  in  cases  of  tight 
phimosis  or  of  edema  of  the  prepuce. 

4.  The  Abortive  Treatment  of  Acute  Gonorrhea. 

The  term  "abortive  treatment"  it  is  not  absolutely  accurate,  strictly 
speaking.  The  gonococci  penetrate,  as  we  have  pointed  out  above,  with 
great  rapidity  into  the  substance  of  the  epithehum.  A  really  abortive 
treatment  would  therefore  imply  the  destruction  of  the  epithelial  layers,  as 
otherwise  the  chorion  would  not  be  reached,  and  the  gonococci  would  not 
all  be  killed  immediately. 

Such  therapy,  if  it  were  at  our  disposal,  would  work  such  havoc  that  the 
advantage  derived  by  the  wholesale  destruction  of  the  gonococci  would 
not  compensate  for  the  damage  done,  or  justify  its  use. 

However,  in  a  looser  sense,  one  may  speak  of  an  "  abortive  treatment," 
and  it  is  really  remarkable  what  good  results  can  be  obtained  by  the  imme- 
diate injection  of  antiseptics  into  the  urethra  under  certain  well-defined 
conditions. 

As  has  been  explained  in  Chapter  V.,  the  gonococci  reach  the  surface  of 
the  cylindrical  epithelium  almost  at  once,  and  enter  it  from  the  third  day  on. 
They  conceal  themselves  in  it,  so  much  so  that  they  cannot  be  dislodged  by 
irrigations  and  injections,  which  merely  pass  over  the  mucous  membrane. 

It  is  thus  evident  that  an  abortive  treatment  can  only  be  successful  if  it 
is  instituted  within  the  first  forty- eight  hours  after  the  first  signs  of  the  dis- 
charge appeared.  After  that  time  it  is  bound  to  be  useless,  and  it  may 
evQn  do  harm  and  give  rise  to  comphcations,  such  as  hemorrhage  from  the 
urethra,  cystitis,  etc. 

Quite  a  number  of  methods  may  be  used  for  aborting  an  attack  of  gonor- 
rhea— namely:  ,    t  •    j_- 

1.  injections. 

2.  Irrigations. 

3.  Intra-urethral  dressings. 

4.  Ecouvillonnage  of  the  urethra. 

1.  Abortive  Injections. — A  great  number  of  substances  have  been  advo- 
cated for  aborting  rapidly  an  attack  of  gonorrhea.  The  chief  ones  are  the 
following : 

Silver  Nitrate. — For  over  a  century  attempts  have  been  made  to  abort 
gonorrhea  by  means  of  intra-urethral  injections  of  silver  nitrate.  The 
sahent  point — and  all  the  advocates  of  this  treatment  are  agreed  in  this 
respect — is  to  apply  the  drug  during  the  first  two  or  three  days  after  the 
infection  took  place. 

Diday  used  injections  varying  in  strength  from  1  to  5  per  cent.,  employ- 


THE  TREATMENT  OF  ACUTE  GONORRHEA      299 

ing  occasionally  a  20  per  cent,  solution.     He  obtained  an  average  of  60  per 
cent,  of  cures. 

Ricord  never  used  a  stronger  solution  than  3  or  4  per  cent. 

The  immediate  effects  of  this  abortive  treatment  consisted  in  an  intense 
pain,  especially  along  the  cauterized  region,  reddening  and  swelHng  of  the 
lips  of  the  meatus,  a  thick,  sometimes  yellowish,  sero-sanguineous  oozing, 
and  severe  discomfort  during  micturition  for  one  or  two  days.  If  the 
abortive  injection  was  successful,  the  inflammatory  manifestations  subsided, 
and  all  discharge  disappeared.  But  this  was  not  common.  Therapeutic 
failures  were  the  rule,  and  often  complications  set  in,  such  as  complete 
retention,  epididymo-orchitis,  cystitis,  prostatitis,  etc. 

Delfosse  practised  instillations  at  the  level  of  the  bulb  with  a  2  per  cent, 
solution  of  silver  nitrate,  which  he  repeated  every  other  day.  If  after  four 
or  five  instillations  the  gonococci  were  still  found,  he  discarded  this  abortive 
treatment. 

Pontoppidan  instilled  a  few  drops  of  a  2  per  cent,  solution  of  silver  nitrate 
into  the  fossa  navicularis  after  the  patient  had  passed  water,  and  thus  he 
cured  a  third  of  his  cases. 

Ulmann  was  in  the  habit  of  injecting  3  to  5  c.c.  of  a  2  per  cent,  solution 
of  silver  nitrate  into  the  urethra,  where  the  liquid  was  allowed  to  act  for  two 
minutes. 

Feleki  passed  a  urethroscopic  tube  as  far  as  the  bulb,  and  then,  as  he 
gradually  withdrew  it,  he  painted  the  urethral  mucous  membrane  with  a 
brush  soaked  in  a  5  per  cent,  solution  of  silver  nitrate.  In  very  early  cases 
with  a  barely  noticeable  secretion,  one  of  these  applications  was  sufficient  to 
produce  a  cure.  In  the  others  this  intervention  had  to  be  repeated  several 
times  after  two  or  three  days. 

Engelbreth^  of  Copenhagen  also  uses  silver  nitrate  for  aborting  gonorrhea. 
In  cases  which  are  one  to  three  days  old,  he  irrigates  the  anterior  urethra 
with  500  c.c.  of  a  warm  solution  at  body  heat,  containing  0*25  to  0"5  per  cent. 
of  the  salt. 

Four  irrigations  of  the  anterior  urethra  are  required — one  at  the  first 
consultation,  the  second  one  six  to  twelve  hours  later,  and  the  others  at 
intervals  varying  between  ten  and  twelve  hours.  The  whole  treatment  is 
thus  completed  in  forty- eight  hours. 

This  abortive  treatment  is  only  indicated  on  the  second  and  third  day 
of  the  disease,  when  the  meatus  is  not  inflamed,  and  the  urine  in  the  first 
glass  is  clear,  although  it  contains  flakes. 

Engelbreth  claims  to  have  had  great  success  with  this  treatment;  85  per 
cent,  of  his  cases  were  cured. 

1  Engelbreth,  Rev.  Prat,  des  Mai.  des  Org.  Genito-Urin.,  March  1,  1904,  p.  26,  and 
Ann.  d.  Org.  Genito-Urin.,  1904,  p.  922. 


300  GONOREHEA 

Melmi  of  Bucliarest^  also  believes  in  aborting  gonorrhea  by  means  of  con- 
centrated solutions  of  silver  nitrate.  He  discounts  Engelbreth's  method, 
which,  according  to  him,  is  liable  to  convey  some  of  the  strong  silver  solution 
into  the  bladder.  He  thinks  that  the  vesical  mucous  membrane  could  thup 
be  injured,  and  in  order  to  obviate  this  he  has  invented  straight  metal  tubes 
which  are  perforated  by  a  great  number  of  little  holes  at  one  end,  and  are 
attached  to  a  syringe  at  their  other  extremity.  These  tubes,  which  are  used 
in  sizes  corresponding  to  Nos.  24  to  28,  efface  the  folds  in  the  urethral  mucous 
membrane,  and  allow  it  to  be  cauterized  more  thoroughly. 

For  recent  cases,  which  are  not  older  than  three  days.  Dr.  Melun  proposes 
to  proceed  as  follows:  The  patient  makes  water,  and  the  anterior  urethra  is 
then  washed  with  distilled  water,  in  order  to  give  the  silver  a  chance  of 
exerting  its  maximum  effect.  One  of  Melmi's  tubes  (No.  24,  26,  28)  is  then 
passed.  A  syringe  is  affixed,  and  a  20  to  33  per  cent,  solution  of  silver  nitrate 
is  injected.  This  infection  is  given  from  behind  forwards,  as  the  instrument 
is  being  gradually  withdrawn,  and  only  affects  the  anterior  urethra.  Violent 
pain,  accompanied  by  a  profuse  discharge,  usually  follows  upon  this  treat- 
ment. It  is  repeated  after  twelve  to  twenty-four  hours,  a  weaker  solution, 
10  to  20  per  cent.,  being  used.     After  this  the  gonorrhea  is  cured. 

This  treatment  is  exceedingly  painful,  and  Dr.  Melun  dwells  upon  the 
necessity  of  always  obtaining  the  formal  consent  of  the  patient  previously. 

Protargol. — Bettmann^  uses  the  following  solution: 

Protargol  . .  . .  . .  . .  . .     10  grammes. 

Hot  distilled  water  . .  . .  . .  . .     45         ,, 

Glycerine  . .  . .  . .  . .  . .     q.s.  ad  100  c.c. 

He  has  a  special  instrumental  outfit  which  allows  him  to  apply  this  solu- 
tion with  a  brush  to  the  urethral  mucous  membrane.  The  manipulations 
are  delicate,  and  could  not  possibly  be  carried  out  by  the  patient. 

Ahlstrom^  uses  a  2  or  4  per  cent,  solution,  of  which  he  injects  5  to  10 
grammes  twice  daily  for  four  to  five  days.  After  three  to  five  days  he 
injects  a  1  or  2  per  cent,  solution  twice  in  the  twenty-four  hours,  and  allows 
it  to  be  retained  for  ten  to  fifteen  minutes.  In  100  cases  he  claims  to 
have  had  only  thirteen  failures,  and  in  eight  complications  arose  (posterior 
urethritis,  prostatitis,  epididymitis,  and  strictures). 

Argonin  has  been  chiefly  advocated  by  Dr.  Follen  Cabot,"*  of  New  York, 
for  the  abortive  treatment  of  gonorrhea.  He  only  attacks  recent  cases  in 
which  the  discharge  has  only  been  noted  for  thirty- six  to  forty- eight  hours. 
He  begins  by  washing  the  urethra  with  hot  water,  and  then  he  passes  a  soft 

1  Melun,  Rev.  Prat.  d.  Mai.  d.  Org.  Genito-Urin.,  September  1,  1904,  p.  213. 

2  Bettmann,  Milnch.  Med.  Woch.,  1904,  No.  28. 

3  Ahlstrom,  ia  Wossidlo,  loc.  cit. 

*  FoUen  Cabot,  Philadelphia  Medical  Journal,  January  26,  1901. 


THE  TEEATMENT  OF  ACUTE  GONORRHEA      301 

catheter  as  far  as  the  bulb.  He  injects  5  to  8  c.c.  of  a  10  per  cent,  solution 
of  argonin  through  the  instrument  and  withdraws  it,  taking  care  that  the 
solution  is  retained  in  the  urethra.  This  is  achieved  by  pressing  the  hps 
of  the  meatus  together.  After  five  to  ten  minutes  he  arms  himseK 
with  a  mounted  swab  soaked  in  a  10  per  cent,  solution  of  argonin,  and  pushes 
it  into  the  anterior  urethra.  As  the  walls  are  kept  apart  by  the  fluid  which 
has  been  injected,  the  wool  and  holder  reach  the  bulb  without  difficulty. 
The  fluid  is  then  allowed  to  escape.  All  parts  of  the  mucous  membrane 
thus  come  into  contact  with  the  wool  and  the  argonin,  with  which  it  has 
been  impregnated,  as  the  holder  is  gradually  withdrawn.  This  treatment  is 
repeated  twice  daily,  stronger  and  stronger  solutions  being  used,  until  a 
sbrength  of  30  per  cent,  is  reached.  The  solutions  should  always  be  fresh 
and  be  specially  prepared  for  the  occasions,  because  this  silver  salt  does  not 
keep  well  in  solution.  Cabot  claims  to  have  obtained  excellent  results 
with  his  method.  In  seven  out  of  eight  cases  he  aborted  the  disease.  Ac- 
cording to  him,  there  is  no  risk,  and,  as  far  as  his  experience  goes,  no  com- 
plications arise  during  or  after  the  treatment. 

Argyrol  has  been  advocated  by  De  Sard,  Janet,  and  Paul  Guillon  {vide 
p.  286). 

Alhargin  is  used  by  Wossidlo^  in  1  :  3,000  solutions,  which  the  patient 
has  to  inject  four  to  six  times  per  day,  as  required,  into  his  anterior  urethra, 
where  it  is  retained  for  five  minutes. 

2.  Urethro- Vesical  Irrigations  with  Permanganate. — Amongst  the  drugs 
which  are  destined  to  render  the  urethral  mucous  membrane  less  susceptible 
to  the  action  of  the  gonococcus,  and  less  favourable  for  its  growth,  ^potassium 
'permanganate  occupies  the  first  rank. 

Janet's  Abortive  Treatment. — Janet  was  the  first,  in  1892,  to  carry  out 
urethro-vesical  irrigations  without  a  catheter  on  a  large  scale,  and  to  render 
them  popular.  The  principle  of  his  treatment  was  based  on  the  fact  that, 
unlike  the  silver  salts,  which  give  rise  to  a  purulent  reaction,  permanganate 
produces  a  serous  secretion  within  the  urethral  membrane  which  renders 
it  a  bad  soil  for  the  development  of  the  gonococcus. 

The  chief  points  in  connection  with  the  abortive  treatment  by  means  of 
permanganate  irrigations  are  the  following : 

1 .  When  should  one  attempt  to  abort  an  Attach  of  Gonorrhea  by  Means  of 
Permanganate  Irrigations  ? — Only  within  the  first  forty- eight  hours  after  the 
first  appearance  is  there  any  hkehhood  of  this  treatment  being  successful. 

2.  What  Doses  shoidd  be  used? — Janet  recommended,  in  1892,  to  give 
three  irrigations  on  the  first  day  at  five  hours'  interval,  using  dilutions 
of  1  : 2,000,  1  :  1,500,  and  1  :  1,000,  respectively.  For  the  second  and 
followiilg  days,  five  days  in  all,  he  recommended  two  irrigations  with  a 

1  Wossidlo,  loc.  cit.,  p.  87. 


302 


GONOEEHEA 


1  : 2,000  solution  per  day.     This  treatment  proved  most  irritating  to  the 
urethra,  so  much  so  that  the  patients  were  unable  to  continue  it. 

Janet  has  since  then  regulated  his  method  in  all  its  details,  as  shown  in 
the  table  below.  A.U.  stands  for  anterior  urethra;  2  U.  indicates  that  both 
the  posterior  and  the  anterior  urethra  should  be  irrigated. 


Day. 

8  a.m. 

Noon. 

9  p.m. 

1st 

A.U.  1  :  1,000 

A.U.  1  :  1,000 

2nd 

A.U.  1  :  3,000 

— 

A.U.  1  :  4,000 

3rd 

2  U.  1  :  2,000 

— 

2  U.  1  :  4,000 

4th 

— 

2  U.  1  :  2,000 

— 

5th 

2  U.  1  :  2,000 

— 

2  U.  1  :  2,000 

6th 

— 

2  U.  1  :  2,000 

— 

7th 

— 

2  U.  1  :  1,000 

— 

8th 

— 

2  U.  1  :  1,000 

— 

9th 

— 

2  U.  1  :  1,000 

— 

10th 

A.U.  1  :  1,000 

2  U.  1  :  1,000 

— 

We  fully  endorse  this  second  method  of  his,  but  it  should  be  clearly 
understood  that  it  is  only  applicable  within  forty- eight  hours  after  the 
appearance  of  the  discharge,  before  micturition  and  erection  have  become 
painful,  and  in  the  absence  of  any  severe  local  inflammation.  With  these 
restrictions  this  treatment  is  capable  of  giving  excellent  results. 

If  applied  on  the  first  day,  it  yields  87  per  cent,  of  cures,  but  on  the 
fifth  day  only  11  per  cent. 

Under  the  influence  of  this  treatment  a  marked  serous  discharge  is 
developed,  which  diminishes  and  stops  within  a  few  hours,  making  room  for 
the  ordinary  whitish  discharge. 

When  the  gonorrheal  discharge  is  profuse,  and  has  lasted  for  three  days 
or  more,  and  when  micturition  and  erection  have  become  painful,  this 
therapy  is,  in  our  opinion,  contra-indicated.  The  irrigations  should  then  be 
replaced  by  the  antiphlogistic  treatment  outlined  above. 

Once  this  latter  therapy  has  led  to  the  disappearance  of  all  painful  and 
inflammatory  phenomena — i.e.,  towards  the  end  of  the  second  or  beginning 
of  the  third  week — then  the  permanganate  irrigations  may  be  resumed 
without  fear.  At  that  stage  the  inflammation  is  much  less  acute  and  the 
gonococci  are  much  less  aggressive.  It  is  therefore  usually  sufficient  to 
give  but  one  urethro-vesical  irrigation  in  the  course  of  twenty-four  hours. 
The  doses  employed  should  vary  between  1 :  4,000  and  1: 1,000. 

In  the  vast  majority  of  cases  this  treatment  removes  the  discharge.  As 
a  rule,  the  latter  disappears  after  twelve  to  fifteen  irrigations.  Failures  are 
either  due  to  a  faulty  technique  or  to  a  comphcation  which  should  be  sought 
for  carefully ;  the  urethritis  has  become  chronic. 


THE  TREATMENT  OF  ACUTE  GONORRHEA       303 

There  is  a  great  difference  in  the  behaviour  of  individual  cases.  The 
first  attack  of  gonorrhea  is  hardly  ever  curable  by  means  of  abortive 
measures;  but  in  patients  who  have  had  attacks  previously,  and  whose 
urethral  mucous  membrane  has  therefore  been  modified,  the  results  are  much 
more  encouraging.    It  is  almost  usual  to  find  the  abortive  method  successful. 

Janet's  irrigations,  whether  used  at  an  early  stage  as  abortive  therapy, 
or  later  when  the  discharge  was  already  diminishing,  have  been  accused  of 
being  frequently  the  cause  of  complications:  posterior  urethritis,  orchitis, 
epididymitis,  cystitis,  lymphangitis,  para-urethral  abscesses,  prostatitis,  and 
.strictures. 

The  fear  of  seeing  a  posterior  urethritis  develop  during  the  treatment  of 
acute  anterior  urethritis  is  certainly  not  unfounded,  and  this  comphcation 
may  occur.  But  it  seems  unjust  to  blame  exclusively  the  irrigations.  In 
most  cases  a  posterior  urethritis  only  develops  under  well-defined  circum- 
stances. Complications  are  relatively  common  if  the  patients  are  un- 
wilhng,  if  they  contract  their  sphincter  unconsciously  and  prevent  the  fluid 
from  passing  into  the  bladder;  but  they  are  rare  if  one  makes  use  of  the  Uttle 
manipulations  which  render  the  penetration  of  the  liquid  into  the  posterior 
urethra  easy,  and  especially  if  one  watches  daily  the  condition  of  the  prostate 
by  rectal  palpation,  as  long  as  the  irrigations  are  given. 

Although  this  method  is  of  great  service  for  the  abortive  treatment  of 
gonorrhea,  it  is  true  that  doctor  and  patient  are  very  much  tied  by  it,  and 
therefore  it  is  almost  impossible  to  apply  it  to  hospital  patients  as  a  routine 
measure. 

3.  Intra-Urethral  Dressings. — Boureau^  has  recommended  the  use  of 
intra- urethral  dressings  for  aborting  attacks  of  gonorrhea. 

His  "  uretro-meche  "  was  a  kind  of  wick,  made  of  cotton- wool,  which  he 
impregnated  with  a  O'l  per  cent,  perchloride  of  mercury  ointment.  It  was 
soft  and  phable,  and  was  introduced  into  the  urethra,  after  the  usual  aseptic 
precautions  had  been  taken,  by  means  of  a  stilette.  One  of  its  ends  was 
provided  with  a  piece  of  string,  which  served  as  guide,  and  was  allowed  to 
hang  out  of  the  meatus.  One  then  covered  the  orifice  with  a  piece  of  wool, 
and  brought  the  prepuce  into  its  normal  position.  This  tampon  was  sup- 
posed to  be  retained  for  three  to  seven  hours,  after  which  time  it  was  washed 
away  by  a  normal  micturition.  It  should  never  be  pulled  out.  Further 
curative  measures  resorted  to  by  Boureau  consisted  in  injections  of  corrosive 
subhmate,  which  were  given  through  a  soft  rubber  catheter  for  eight  days 
or  so.  Only  the  anterior  urethra  was  treated,  twice  daily  in  the  beginning, 
and  later  on  only  once  in  twenty-four  hours. 

Insufflations  with  Powders. — It  has  been  proposed  to  insufflate  antiseptic 
powders  into  the  urethra,  and   boric  acid,  bismuth  subnitrate,  iodoform, 

1  Boureau,  Moscow  International  Medical  Congress,  1897. 


304  GONOEEHEA 

calomel,  etc.,  have  been  used.  The  instruments  invented  for  this  treatment 
are  partly  very  ingenious,  but  the  results  do  not  appear  to  have  been  very 
encouraging. 

Medicated  Bougies  (urethral  suppositories,  "  gonostyh,"  etc.),  consisting 
of  solidified  glycerine  or  cocoa-butter,  or  some  other  suitable  basis,  and  a 
certain  percentage  of  an  antiseptic,  have  also  been  advocated.  But  they  have 
not  given  any  appreciable  therapeutic  results. 

4.  Ecouvillonnage  of  the  Urethra. — Huguet  in  1889  practised  "ecouvil- 
lonnage"  before  he  gave  an  injection.  He  first  anesthetized  the  urethra 
with  cocain,  and  then  he  swept  the  urethra  with  a  brush  resembhng  a  test- 
tube  brush.  The  result  of  this  intervention  consisted  in  profuse  bleeding 
from  the  mucous  membrane. 

It  was  intended  to  bring  about  the  desquamation  of  the  mucosa  by 
destroying  the  epidermis  completely,  and  in  this  way  to  enable  the  subse- 
quent injections  of  antiseptics  to  reach  the  recesses  in  which  the  pathogenic 
organisms  had  sought  shelter. 

Guiard  has  also  practised  this  treatment,  following  it  up  with  injections 
of  1  :  1,000  permanganate. 

It  does  not  seem  as  if  this  procedure  could  be  recommended. 

5.  The  Treatment  of  Acute  Posterior  Urethritis. 

The  treatment  of  acute  posterior  urethritis  should  be  above  everything 
prophylactic — -that  is  to  say,  one  should,  in  accordance  with  Janet's  table 
given  above,  allow  the  permanganate  to  enter  the  posterior  urethra  during  the 
course  of  the  treatment.  If,  as  we  have  explained  above,  these  irrigations 
reach  the  posterior  urethra  easily  and  without  difficulty,  the  occurrence  of  a 
posterior  urethritis  will  be  frustrated  in  the  overwhelming  majority  of  cases. 

Posterior  urethritis  is  a  disagreeable  compUcation  which  should  be 
traced  and  diagnosed  by  the  surgeon  as  soon  as  it  makes  its  appearance. 
The  cardinal  symptoms  which  indicate  the  imphcation  of  the  posterior 
urethra,  and  prove  that  the  inflammation  of  the  anterior  urethra  has  spread 
to  the  posterior,  should  always  be  looked  for  carefully,  whilst  the  patient  is 
under  treatment. 

These  cardinal  symptoms  are,  briefly :  turbid  urine  in  the  last  glass  or  glasses, 
frequency  and  difficulty  of  micturition,  and  sometimes  also  terminal  hematuria. 

Once  these  symptoms  have  been  found  to  be  present,  urethro-vesical 
irrigations  with  permanganate  should  be  resorted  to  immediately.  It  is 
essential  that  the  permanganate  should  reach  the  bladder,  that  rectal  palpa- 
tion be  carried  out,  and  that  the  prostate  be  massaged.  Such  is  the  local 
treatment,  which  we  cannot  advocate  too  strongly,  and  in  particular  we 
wish  to  recommend  its  early  apphcation.  The  technical  details  are  de- 
scribed farther  on  {vide  Chapter  XII.). 


THE  TREATMENT  OF  ACUTE  GONORRHEA       305 

This  local  treatment  should  be  combined  with  the  use  of  rectal  supposi- 
tories, such  as — 

Ung.  hydrarg.       . .  . .  . .  . .     0-05  grammo. 

Cocoa-butter  .  .  .  .  .  .  .  .      q.s. 

One  suppository  of  this  composition  to  be  introduced  every 
night  when  going  to  bed. 

Hot  rectal  irrigations  (45°  or  even  50°  C.)  given  daily  are  also  of  great 
service  if  the  patient  can  bear  them.  Absolute  rest  is  to  be  recommended. 
Hot  baths  of  long  duration,  and,  lastly,  1  to  2  grammes  of  helmitol  or  uro- 
tropin  per  day,  taken  at  mealtimes,  should  also  be  prescribed. 

Such  is,  broadly  speaking,  the  treatment  of  a  posterior  urethritis  which 
makes  its  appearance  towards  the  dechne  of  gonorrhea.  If  an  acute  posterior 
urethritis  develops  suddenly  shortly  after  the  beginning  of  the  infection, 
and  when  the  inflammation  is  very  considerable,  then  any  kind  of  irrigation 
should  be  strictly  forbidden.  For  cases  of  this  kind  the  hygienic  and  general 
measures  which  we  have  indicated  are  required,  and  balsams  should  be 
given  internally.  The  latter  will  cope  with  the  first  accidents,  and  have  a 
favourable  influence  on  the  illness,  providing  they  are  not  given  for  too  long 
a  time. 

6.  The  Serum  Therapy  of  Gonorrhea. — The  serum  therapy  of  gonorrhea 
is  of  quite  recent  date. 

It  is  nowadays  estabhshed  beyond  doubt  that  the  gonococcus  is  capable 
of  entering  the  blood-stream,  and  of  thus  setting  up  a  genuine  gonococcal 
'pyemia,  in  the  course  of  which  a  variety  of  manifestations  develop,  as  the 
organism  enters  the  different  organs.  This  knowledge  has  been  the  starting- 
point  of  a  new  therapy,  as  far  as  gonorrhea  is  concerned.  Curative  attempts 
have  been  made  in  two  directions:  one  has  endeavoured  firstly  to  modify 
the  blood,  in  order  to  render  it  refractory  to  the  invasion  by  the  microbe,  and 
secondly  to  increase  its  gonococcocidal  powers  after  the  cocci  had  entered  it. 

The  idea  of  giving  a  little  hypodermic  injection,  and  of  thus  freeing  the 
whole  body  immediately  from  all  gonococci,  is  so  seductive  that  it  neces- 
sarily obtained  a  favourable  reception  in  all  quarters.  Unfortunately,  the 
results  have  so  far  not  justified  the  hopes  which  had  been  raised  by  this 
therapy. 

Daily  experience  shows  that  a  first  attack  of  gonorrhea  conveys  no 
immimity  of  any  duration. 

Rogers^  thought  that  the  exasperatingly  chronic  course  of  certain  gonor- 
rheal joint  lesions  was  due  to  a  natural  deficiency  of  antibodies  or  to  their 
inadequate  formation  within  the  infected  person.  In  both  alternatives  the 
therapeutic  administration  of  antibodies  could  be  expected  to  hasten  the 

^  Rogers,  Journal  of  American  Medical  Association,  1906,  vol.  Ixvi.,  p.  263,  No.  4. 

20 


306  GONOERHEA 

curative  process,  and  thus  lie  conceived  the  plan  of  preparing  and  injecting 
an  antigonococcal  serum. 

For  this  purpose  he  cultivated  gonococci  on  peptonized  broth  to  which 
ascitic  fluid  had  been  added.  After  ten  to  fifteen  days  these  cultures  were 
injected  into  the  peritoneal  cavity  of  a  rabbit.  After  six  injections  the 
animal  was  held  to  be  sufiiciently  immunized,  and  was  bled  from  the  vein 
of  the  ear.  The  serum  was  collected  aseptically,  and  put  up  in  sealed  glass 
tubes.  Its  specific  antitoxic  properties  were  tested  by  means  of  the  follow- 
ing experiment:  Rabbits,  which  had  been  injected  with  1  c.c.  of  the  specific 
serum,  received  subsequently  3  c.c.  of  gonococcal  toxin.  They  displayed 
merely  a  slight  rise  of  temperature,  whilst  the  control  animals,  which  had 
not  been  immunized  with  the  serum,  died  within  three  hours. 

Rogers  treated  eight  cases  of  gonorrheal  rheumatism  with  his  anti- 
gonococcal serum.  Two  of  them  failed  to  respond,  whilst  the  six  others 
reacted  in  a  characteristic  manner.  Twenty-four  or  thirty-six  hours  after 
the  first  injection  the  fever  disappeared,  the  pain  diminished,  and  the 
articular  swelhngs  subsided.     In  eight  or  ten  days  no  symptoms  were  left. 

Rogers  is  thus  of  the  opinion  that  antigonococcal  serum  is  of  considerable 
value  in  the  treatment  of  gonorrheal  joint  lesions. 

In  1909  Carlos  Mainini^  made  some  interesting  researches  on  gonorrheal 
vaccines  in  Professor  Widal's  laboratory.  He  inoculated  tubes  containing 
Wertheim's  ascites-agar  medium  with  gonoccoci  taken  from  a  case  of  acute 
urethritis.  After  the  cultures  had  well  developed,  5  c.c.  of  a  0-9  per  cent. 
saHne  solution,  to  which  0'5  per  cent,  phenol  had  been  added,  were  poured 
into  each  tube.  The  tubes  were  then  well  shaken  in  order  to  free  the 
colonies  from  the  agar  surface.  An  emulsion  containing  gonococci  was 
thus  obtained  and  drawn  up  into  the  bulbous  portion  of  a  pipette.  After 
the  ends  of  the  latter  had  been  sealed  in  the  flame,  the  emulsion  was  heated 
on  the  water-bath  for  thirty  minutes  to  70°  C.  The  organisms  were  then 
counted,  and  the  emulsion  was  diluted  to  1 :  100,  or  1 :  1,000  if  necessary. 

Mainini  has  treated  six  patients  with  these  vaccines,  and  found  the  pain 
to  disappear  in  every  case.  According  to  him,  gonococcal  vaccines  have  a 
marked  analgesic  effect  upon  gonorrheal  articular  lesions. 

Dr.  Schmidt  2  of  Chicago  has  also  studied  the  vaccine  treatment  of 
gonorrhea.     He  uses  two  different  preparations — a  serum  and  a  vaccine. 

His  serum  is  prepared  by  injecting  a  virulent  culture  of  gonococci  into 
the  peritoneum  of  a  non-castrated  ram.  During  the  following  three  weeks 
the  animal  receives  one  dead  culture  of  virulent  gonococci  per  week,  and 

1  Mainini,  Presse  Medicale,  January  15,  1909. 

2  Louis  E.  Schmidt,  "  The  Gonorrheal  Vaccine  Treatment  and  the  Antigonococcic 
Serum  Treatment  in  Reference  to  Gonorrhea  and  its  Complications,  but  with  Particular 
Reference  to  Joint  Involvements  "  (reprint  from  the  Therapeutic  Gazette,  September  15, 
1910). 


THE  TREATMENT  OF  ACUTE  GONORRHEA      307 

then  for  another  seven  weeks  an  injection  of  living  virulent  organisms 
every  seven  days.  When  this  process  is  completed,  the  ram  is  immunized 
and  ready  for  bleeding.  One  ascertains  that  the  blood  is  sterile,  in  which 
case  it  can  be  used;  2  c.c.  are  injected  into  patients  suffering  from  gonorrhea 
for  one,  two,  three,  or  four  consecutive  days. 

Schmidt's  gonococcal  vaccine  is  made  from  a  virulent  culture  of  gonococci 
which  has  been  heated  to  60°  C.  for  fifty  minutes.  The  cocci  are  then 
counted,  and  tubes  containing  10,000,000,  20,000,000,  100,000,000,  and 
500,000,000  gonococci  per  1  c.c.  are  prepared.  These  dead  organisms, 
which  are  suspended  in  normal  saUne  solution,  are  put  up  in  sealed  am- 
poules. According  to  the  requirements  of  the  case,  2  to  10  c.c.  of  this 
vaccine  are  injected  on  two  to  four  occasions  at  intervals  varying  from  three 
to  twelve  days. 

Dr.  Maute  ^  has  studied  the  action  of  vaccines  prepared  by  Wright's 
method  on  gonorrheal  affections.  His  fourteen  male  patients  suffered  of 
acute  gonococcal  urethritis.  All  of  them  except  one  had  their  first  attack, 
and  the  first  injection  of  vaccine  was  given  three  to  six  days  after  the  onset 
of  their  discharge.  They  had  not  undergone  any  other  treatment  pre- 
viously. 

Excepting  two  cases,  the  vaccines  were  prepared  specially  for  every 
patient  from  the  gonococci  found  in  his  own  urethra.  The  organisms  were 
cultivated  on  ascites-agar,  and  killed  by  heating  to  53°  C.  for  one  hour.  The 
doses  injected  varied  from  5,000,000  to  30,000,000. 

The  injections  were  given  into  the  subcutaneous  cellular  tissue,  and  pro- 
duced no  local  reaction.  On  the  other  hand,  if  the  patients  have  gonococci 
in  their  system,  an  intradermic  injection,  even  in  the  dose  of  5  drops  of  a 
vaccine  containing  25,000,000  per  c.c,  produces  a  red,  purplish,  edematous 
halo  of  20  to  30  millimetres  diameter  around  the  point  of  injection.  This 
local  reaction  could  be  used  as  a  diagnostic  means  for  detecting  a  gonococcal 
infection,  if  numerous  researches  prove  it  to  be  constant. 

The  immediate  effect  of  every  injection  upon  the  course  of  the 
disease  was  nil,  except  in  one  case.  In  this  instance  the  first  injection  of 
5,000,000  caused  an  exacerbation  of  the  discharge  for  ten  hours,  which  was 
followed  on  the  next  five  days  by  a  diminution^^of  the  discharge.  The  second 
injection  was  given  six  days  after  the  first,  the  same  dose  being  used.  The 
discharge  again  increased  for  twelve  hours  or  so,  whereupon  it  diminished. 
At  the  end  of  the  third  week  the  patient  could  be  considered  to  be  cured. 

In  the  other  cases  the  duration  of  the  illness  was  not  modified  by  the 
vaccine  therapy.  The  discharge  disappeared  four  weeks  to  two  months 
after  the  onset  of  the  illness,  and  in  one  case  it  lasted  over  three  months. 
Perhaps  one  should  note  certain  pecuharities  in  the  evolution  of  the  disease. 

1  Maute,  8oc.  Biol,  March  27,  1919,  and  Journ.  des  Praticiens,  May  29,  1909. 


308  GONORKHEA 

As  a  rule,  the  florid  state  passes  rapidly  into  the  period  of  definite  cure. 
The  morning  discharge  of  the  period  of  decline  often  ceased  abruptly  in  a 
few  days.  For  instance,  a  patient  who  five  or  six  days  previously  had  a 
copious  discharge,  from  which  gonococci  could  be  cultivated,  showed  at 
the  following  examination  only  a  few  light  muco- epithelial  filaments  which 
contained  no  gonococci.  One  should,  however,  not  forget  that  the  pecuUar 
course  of  the  illness  may  have  been  largely  due  to  the  complete  absence  of 
local  treatment.  During  the  height  of  the  disease  the  discharge  was 
definitely  gonorrheal,  but  the  other  phenomena  were  reduced  to  a  minimum : 
hardly  any  pain  or  none  on  making  water,  and  the  erections  painful  in  four 
cases  only.  All  fourteen  cases  remained  uncomplicated.  A  fifteenth 
patient,  who  had  been  suffering  for  seven  weeks  and  had  developed  an 
attack  of  epididymo-orchitis  whilst  he  was  being  treated  with  permanganate 
irrigations,  showed  no  improvement  or  other  change  after  he  was  injected 
with  vaccines. 

To  resume,  apart  from  one  case  the  course  of  the  illness  was  hardly 
affected  by  the  vaccine  therapy.  A  cure  was  obtained  after  the  same  time 
as  that  which  is  required  with  the  classical  irrigation  treatment.  There 
seems  no  reason  for  supposing  that  the  patients  would  not  have  been  cured 
equally  quickly  without  the  vaccines,  if  they  obeyed  the  few  hygienic  pre- 
scriptions of  the  expectant  therapy. 

According  to  Dr.  Maute,  vaccine  therapy  is  often  efficacious  in  the  treat- 
ment of  gonococcal  pyemia,  of  which  gonorrheal  rheumatism  is  the  most 
common  manifestation.  Arthralgia,  sero-fibrinous  exudates,  and  purulent 
articular  lesions,  all  improve  with  vaccines.^ 

After  vaccination  the  pains  disappear,  and  the  fever  falls  usually  in  a 
constant  fashion.  The  effusions  are  absorbed  rapidly,  and  in  some  cases 
one  can  begin  to  move  and  to  massage  the  joint  in  eight  days. 

Vaccine  therapy  by  means  of  Wright's  opsonizing  method  has  also  been 
studied  by  Dr.  Jarvis.^  He  finds  that  the  treatment  is  harmless,  and  that 
an  autogenous  vaccine  is  unnecessary.  One  may  therefore  use  a  stock 
vaccine  instead  of  preparing  a  special  vaccine  for  every  case  from  its  own 
gonococci. 

The  injections  are  practically  always  followed  by  a  negative  phase 
which  lasts  forty-eight  hours,  and  is  characterized  clinically  by  an  exacerba- 
tion of  the  symptoms;  a  marked  improvement  then  sets  in,  which  lasts 
three  to  five  days.  At  the  end  of  this  time  a  fresh  injection  of  vaccine 
should  be  given,  but  in  a  bigger  dose. 

Vaccine  therapy  is  more  successful  as  a  treatment  of  the  complications 
of  gonorrhea  than  as  a  cure  for  the  urethritis. 

1  Maute,  Presse  Medicale,  March  15,  1911,  p.  202. 

2  Presse  Medicale,  March  5,  1910,  p.  161. 


CHAPTER  XII 

THE  TREATMENT  OF  CHRONIC  GONORRHEA 

It  is  difficult  to  give  an  accurate  definition  of  the  term  "  chronic  gonor- 
rhea," for  it  is  practically  impossible  to  determine  the  exact  moment  at 
which  an  acute  case  becomes  chronic.  Several  authors  have  tried  to  draw 
the  line  between  the  two  stages  by  fixing  a  time  limit  for  acute  gonorrhea. 
Others  laid  special  stress  on  the  amount  of  pain.  In  themselves,  neither  of 
these  two  points  yield  a  definite  distinction,  but  it  would  seem  that  they 
should  be  taken  into  account  as  well  as  a  third  one,  which  is  very  important 
— namely,  the  amount  of  discharge  and  the  condition  of  the  urine. 

We  may  therefore  say  that  all  attenuated  attacks  of  gonorrhea  are 
chronic  if  they  have  lasted  longer  than  is  usual,  if  they  are  not  accompanied 
by  pain,  and  if  the  urine  is  mostly  clear. 

In  former  days,  "  gleet,"  as  the  disease  is  generally  called,  drove  the 
patients  to  despair  owing  to  its  tenacity,  and  it  proved  a  severe  test  for  the 
patience  of  the  medical  man,  who  in  the  end  very  often  pronounced  the 
patient  to  be  incurable,  and  made  no  attempt  to  ascertain  the  cause  of  the 
chronic  nature  of  the  illness. 

"  If  I  should  go  to  hell,"  Ricord  used  to  say,  "•  I  know  what  I  wiH  be  in  for: 
I  will  find  myself  surrounded  by  patients  suffering  from  gonorrhea,  who 
incessantly  implore  me  to  cure  them." 

This  celebrated  dictum  of  the  master  of  venereology  is  a  good  illustration 
of  the  difficulties  met  with  in  the  treatment  of  gonorrhea. 

Ricord  was  also  fond  of  declaring  that  one  knows  perfectly  well  when  a 
clap  begins,  but  that  it  is  the  privilege  of  God  of  being  able  to  tell  when  it 
will  end. 

Twenty  years  ago  this  statement  corresponded  to  the  facts,  but  now- 
adays it  is  no  longer  justified.  The  methods  of  treatment  have  been  vastly 
improved,  and,  if  used  methodically  and  rationally,  they  allow  one  to  cm-e 
nearly  every  case  of  gleet.  There  are  no  localizations  which  cannot  be 
made  out  and  treated  with  our  modern  therapeutic  and  diagnostic  means. 
When  a  patient  tells  us  that  he  has  tried  all  recognized  and  known  measures 
without  obtaining  a  cure,  one  is  entitled  to  reply:  '"You  have,  however, 
forgotten  one — namely,  the  one  which  would  have  cured  you." 

309 


310  GONOEEHEA 

The  guiding  principle  of  the  treatment  of  chronic  urethritis  consists  in 
applying  a  local  therapy  to  the  localized  lesions  present.  If  one  is  able  to 
diagnose  the  latter  accurately,  and  knows  how  to  treat  them,  a  cure  is 
necessarily  obtained. 

The  first  step,  therefore,  consists  in  making  an  accurate  diagnosis  of  the 
lesions,  as  we  have  explained  in  previous  chapters  (VII.,  VIII.). 

When  the  whole  urethral  mucous  membrane  has  been  inspected  with  the 
aid  of  the  urethroscope,  and  been  found  to  be  healthy,  and  when  all  the 
glands  connected  with  the  urethra  (prostate,  seminal  vesicles,  Cowper's 
glands,  Littre's  glands)  have  been  expressed  and  been  shown  to  yield  no 
pathological  secretions,  then  it  is  impossible  that  the  chronic  urethritis 
should  not  have  been  cured. 


General  Plan  of  the  Treatment  of  Chronic  Urethritis. 

Chronic  urethritis  means  a  urethritis  with  localized  inflammatory  areas. 
It  thus  differs  from  acute  urethritis,  in  which  the  pathological  process  is 
disuse  and  swperficial.  Hence  these  two  conditions  require  a  totally  dif- 
ferent treatment,  and  in  the  case  of  chronic  urethritis  the  best  therapy 
consists,  obviously,  in  dealing  directly  with  the  localized  areas.  In  order 
to  be  able  to  do  this,  one  must  know  how  to  search  for  these  lesions  and  to 
discover  them. 

Broadly  speaking,  the  following  plan  should  be  adopted  for  the  treat- 
ment of  chronic  urethritis : 

1.  Urethro-Vesieal  Irrigations. — The  urine  should  first  be  rendered  clear, 
and  this  is  achieved  by  irrigating  the  patient  with  potassium  permanganate, 
oxycyanide  of  mercury,  corrosive  subhmate,  boric  lotion,  silver  nitrate, 
protargol,  etc.  Once  the  desired  effect  has  been  obtained,  and  when  the 
urine  in  the  first  glass  is  much  clearer,  a  methodical  exploration  of  the 
urethra  becomes  indicated,  and  all  the  localized  patches,  which  may  be 
prolonging  the  disease,  are  sought  for. 

2.  Massage  of  the  Prostate,  of  the  Seminal  Vesicles,  and  of  Cowper's 
Glands. — Once  the  diagnostic  measures  have  shown  the  prostate,  or  the 
seminal  vesicles,  or  Cowper's  glands,  to  be  affected,  massage  of  the  diseased 
gland  or  glands  should  be  resorted  to  until  nothing  abnormal  can  be  found 
in  connection  with  them— ^'.e.,  until  the  discharge  ceases,  the  pain  and 
tenderness  disappear,  and  the  composition  of  the  material  expressed  from 
them  becomes  normal. 

3.  Dilatation  by  Means  of  Curved  Metal  Sounds.— After  the  foci  just 
mentioned  have  been  properly  attended  to  and  been  restored  to  health,  it 
becomes  justifiable  to  introduce  dilators  into  the  urethra,  providing  the 
urine  has  become  perfectly  clear. 


THE  TREATMENT  OF  CHRONIC  GONORRHEA     311 

The  urethral  and  para-urethral  foci  are  then  treated  by  means  of  slow 
and  methodical  dilatation  with  curved  metal  sounds. 

This  dilatation  treatment  is  of  great  importance,  and  serves  a  twofold 
purpose — to  treat  appropriately  the  diseased  patches  within  the  urethral 
mucous  membrane,  and  especially  to  widen  the  passage  and  to  prepare  it 
thus  for  urethroscopy. 

4.  Urethroscopy. — Urethroscopy  should  only  be  resorted  to  after  the 
dilatations  with  curved  sounds  have  opened  the  passage  sufficiently  to  admit 
No.  60  G  without  difficulty.  One  can  then  inspect  the  urethral  mucous 
membrane,  see  the  diseased  areas,  and  determine  the  places  which  require 
to  be  dilated  most. 

5.  Dilatation  with  Four-Bladed  Dilators. — The  other  methods  of  dilata- 
tion which  require  special  instruments,  such  as  those  of  Oberlander,  Koll- 
mann,  and  Frank,  are  then  applied  according  to  the  indications  yielded  by 
the  urethroscopic  examination. 

6.  Urethroscopic  Treatment  Proper. — After  all  these  dilatations  have 
been  carried  out,  the  passage  should  be  again  urethroscoped ;  and  if  localiza- 
tions are  found  which  have  withstood  the  dilatation,  then,  and  only  then, 
should  endo-urethral  interventions  be  resorted  to. 

By  following  systematically  these  indications  it  seems  to  us  impossible 
not  to  cure  all  cases  of  chronic  urethritis. 

DESCRIPTION  OF  THE  MODERN  METHODS  OF  TREATING 
CHRONIC  URETHRITIS. 

The  different  modern  methods  proposed  for  treating  chronic  urethritis 
are  the  following: 

1.  Destruction  of  external  para-urethral  foci-. 

2.  Urethro- vesical  irrigations. 

3.  Urethral  injections. 

4.  Massage  of  the  glands  connected  with  the  urethra. 

5.  Dilatation  of  the  urethra. 

6.  Urethroscopic  treatment. 

7.  Instillations. 

8.  Application  of  heat  to  the  urethral  mucous  membrane. 

9.  Ionization  treatment  of  the  urethral  mucous  membrane. 

10.  Urethral  suppositories. 

11.  Electrolysis  of  the  urethral  mucous  membrane. 


312  GONORRHEA 

1.  The  Destruction  of  External  Para-Urethral  Foci  in  Chronic  Urethritis. 

We  have  pointed  out  on  p.  92  the  importance  of  searching  systematic- 
ally for  any  para-urethral  foci  which  by  their  presence  may  give  the  gono- 
coccus  a  permanent  shelter  and  prolong  the  urethritis  for  ever.  We  will 
now  discuss  their  treatment. 

They  are  most  commonly  found  in  hypospadias  and  in  the  immediate 
neighbourhood  of  the  meatus.  One  variety,  which  is  not  sufficiently  known, 
is  Tyson's  gland. 

Nearly  all  these  para-urethral  localizations  have  a  small,  usually  minute 
orifice  which  leads  to  a  more  or  less  extensive  cul-de-sac. 

Their  treatment  consists  in  their  destruction,  for  which  several  methods 
have  been  proposed: 

1.  Injections.- — One  has  attempted  to  inject  liquid  caustics,  such  as 
concentrated  solutions  of  silver  nitrate  or  of  potassium  permanganate, 
through  the  minute  orifices  of  these  fistulous  tracts,  and  to  obtain  thus  their 
destruction.  This  method,  for  which  exceptionally  fine  needles  are  re- 
quired, never  leads  to  a  radical  cure,  and  cannot  be  recommended.     The 


Fig.  142. — Janet's  Tbajectotome. 

liquids  cannot  be  injected  satisfactorily,  and  hardly  ever  reach  the  fundus 
of  the  infected  cul-de-sac.  Their  action  on  the  walls  of  the  tract  is  much 
too  weak. 

2.  Incision. — To  lay  the  fistulse  widely  open  by  incising  them  is  certainly 
an  excellent  method  when  it  is  applicable. 

Janet  has  invented  a  special  instrument,  his  trajectotome,  for  opening 
these  para-urethral  ducts.  They  subsequently  heal  by  granulating  from 
the  depth  to  the  surface. 

In  certain  cases  it  is  impossible  to  use  this  method,  which,  moreover, 
occasionally  leads  to  considerable  laceration  and  causes  disagreeable 
scarring. 

3.  Cauterization  by  Means  of  the  Galvanic  Cautery. — Preference  should 
be  given  to  the  galvano-caustic  method  in  all  cases  of  para-urethral  ducts. 
A  finely  pointed  platinum  loop  is  introduced,  whilst  cold,  into  the  opening 
of  the  tract;  the  current  is  then  switched  on,  and  in  a  few  moments  the 
entire  tract  is  destroyed.  This  method  gives  excellent  results,  and  is  cer- 
tainly superior  to  any  other  which  has  been  proposed. 

In  some  cases  it  is  of  advantage  to  be  able  to  limit  the  action  of  the 
cautery — for  instance,  if  the  patient  is  afflicted  simultaneously  with  a  para- 


THE  TREATMENT  OF  CHRONIC  GONORRHEA  313 

urethral  duct  and  hypospadias.     Excessive  burning  can  then  be  prevented 
by  the  following  excellent  method  {vide  Fig.  143) : 

A  mounted  swab,  which  has  been  saturated  with  stovain,  is  introduced 
into  the  fossa  navicularis,  and  its  holder  is  allowed  to  drop  by  its  own 
weight.  One  then  applies  the  cautery.  This  procedure  has  three  ad- 
vantages: (1)  The  region  which  is  operated  on  is  anesthetized  to  a  certain 
extent;  (2)  the  para-urethral  fistula  is  made  prominent  and  becomes  more 
visible;  and  (3)  the  action  of  the  galvanic  cautery  cannot  extend  too  far. 

2.  The  Urethro-Vesical  Irrigations. 

The  urethro- vesical  irrigations  should  be  continued  in  chronic  gonorrhea 
as  long  as  the  urethral  mucous  membrane  remains  markedly  inflamed,  and  as 


Fig.  143. — Destruction  of  a  Para-Ubethbal  Tract  with  the  Cautery. 

long  as  the  urine  in  the  first  glass  is  turbid.  The  technique  is  the  same  as 
in  acute  gonorrhea,  and  has  been  fully  described  in  the  previous  chapter 
(v^'c^ep.  278). 

3.  The  Urethral  Injections. 

The  technique  and  the  indications  of  urethral  injections  have  been  dis- 
cussed in  connection  with  acute  gonorrhea  (Chapter  XI.),  and  need  not  be 
gone  into  again.  There  are,  however,  three  methods  of  treatment,  which 
may  be  grouped  under  this  heading,  and  which  require  some  comment,  as 
they  have  some  peculiar  features  of  their  own: 

1.  Permanent  dressings. 

2.  The  combined  action  of  two  drugs  on  the  urethral  mucous  membrane. 

3.  The  application  of  antiseptic  gases  to  the  urethral  mucous  membrane. 


314 


GONORRHEA 


1.  Permanent  Dressings. — Certain  authors  gained  the  impression  that 
a  short  apphcation  of  even  a  powerful  drug  could  not  have  a  sufficiently 
strong  action  on  the  deep  infiltrations  of  the  mucous  membrane;  they 
therefore  advocated  prolonged  applications  of  certain  antiseptics.  Unna, 
Casper,  and  Janet,  used  medicated  bougies  or  ointments  containing  a  large 
proportion  of  silver  nitrate.  Motz  was  of  the  opinion  that  only  aqueous 
solutions  could  be  rehed  on  for  an  efficient  and  easily  controllable  action. ^ 
He  introduced  4  to  5  c.c.  of  an  antiseptic  solution  into  the  urethra,  com- 
pressed the  fossa  navicularis  with  two  fingers  of  the  left  hand,  and  subse- 
quently constricted  the  glans  with  a  tight  dressing.  The  patient  retained 
the  fluid  in  this  way  for  one  to  three  hours.  Motz  uses  chiefly  hermophenyl 
and  oxycyanide  of  mercury ;  he  has  three  solutions  of  different  strengths, 
which  are  chosen  according  to  the  tolerance  of  the  patient : 


Weak  Solution. 

Medium  Solution. 

Strong  Solution. 

Hermophenyl 

Protargol 

Glycerine 

Cocain  hydrochloride 

Distilled  water 

0-50  gramme 
0-50  gramme 
30-00  c.c. 
1  gramme 
1  litre 

0-75  gramme 
0-75  gramme 
30-00  c.c. 
1  gramme 
1  litre 

1  gramme 
1  gramme 
30-00  c.c. 
1  gramme 
1  litre 

If  no  hermophenyl  is  at  hand,  one  may  use  as  substitute  oxycyanide  of 
mercury  in  the  dose  of  0-2  gramme  per  litre  for  the  weak  solution.  These 
dressings  are  applied  every  two,  three,  or  four  days,  and  their  use  should 
be  preceded  by  a  thorough  irrigation  of  the  whole  urethra  with  a  1 :  2,000 
solution  of  oxycyanide  of  mercury. 

If  the  secretions  of  the  chronic  urethritis  still  contain  gonococci,  Motz 
recommends  as  a  permanent  dressing  the  following  solution : 


Medicinal  hydrogen  peroxide 
Distilled  water    . . 


5  CO- 
OS  „ 


This  fluid  should  be  used  daily,  and  be  retained  for  2  to  3  hours. 

It  is  impossible  to  recommend  these  dressings  as  an  exclusive  treat- 
ment for  chronic  urethritis.  They  are  useless  unless  they  are  combined 
with  other  measures.  They,  for  instance,  cannot  bring  about  the  resorption 
of  deep  infiltrations  in  the  urethral  mucous  membrane;  but  they  can  be 
used  with  advantage  in  the  treatment  of  these  inveterate  lesions,  if  a  pro- 
fuse discharge  due  to  adventitious  organisms  be  present.  They  stand  no 
comparison  with  the  methodical  dilatation  of  the  urethra. 

2.  On  the  Combination  of  Silver  and  Zinc  in  the  Treatment  of  Chronic 
Urethritis. —  Sabouraud^  recommended  the  systematic  cauterization  with 

1  Motz,  Ann.  Genito-Urin.,  1903,  p.  426. 

-  Sabouraud,  "  Les  Cauterisations  aux  Deux  Crayons,"  La  Clinique,  February  23, 
1906,  p.  118. 


THE  TREATMENT  OF  CHRONIC  GONORRHEA     315 

two  different  caustics,  which  were  to  be  used  in  succession,  as  a  treatment 
for  chronic  non-specific  ulcerations.  This  interesting  method,  which  is 
apphcable  to  all  wounds  which  are  sluggish  in  their  heahng,  is  said  to  have 
given  excellent  results  in  dermatology. 

It  was  thus  natural  that  one  should  have  attempted  to  benefit  the 
urethral  mucous  membrane  by  applying  this  apparently  so  active  and  effi- 
cacious treatment.  Balzer  and  Tansard^  carried  it  out  in  the  following 
way: 

An  instillation  of  10  to  20  drops  of  a  1  or  2  per  cent,  solution  of  silver 
nitrate  is  given  into  the  anterior  or  posterior  urethra.  One  then  passes 
immediately  a  sound,  made  of  zinc,  No.  40  G,  and  leaves  it  in  the  urethra 
for  one  to  two  minutes,  until  a  reaction  is  obtained.  At  the  end  of  this 
time  the  silver  nitrate  is  reduced,  and  flows  out  of  the  meatus  as  a  blackish 
mass.  A  double  decomposition  has  taken  place;  the  silver  nitrate  is  split 
up  into  free  nitric  acid  and  nascent  colloidal  silver,  and,  on  the  other  hand, 
the  liberated  acid  combines  with  the  zinc,  forming  nitrate  of  zinc.  The 
salt  last  mentioned  is  said  to  be  the  most  active  caustic  in  the  method, 
which,  according  to  the  authors,  is  suitable  for  almost  every  case  of  chronic 
urethritis.  They  say  that  it  is  immaterial  whether  the  anterior  or  the 
posterior  urethra  be  affected,  and  that  it  makes  no  difference  whether  gono- 
cocci  are  present  or  not.  The  most  suitable  cases  are  those  in  which  an 
acute  urethritis  is  subsiding,  but  very  slowly,  and  which  are  hkely  to 
become  chronic. 

If  used  under  these  conditions,  the  cauterizing  effect  of  this  treatment 
is  not  too  severe.  Balzer  and  Tansard  controlled  the  results  of  their  therapy 
by  means  of  the  urethroscope,  and  never  saw  any  trace  of  sloughing. 

This  new  weapon  of  our  therapeutic  arsenal  seems  to  be  of  value  for 
the  treatment  of  chronic  urethritis,  and  to  be  more  efficacious  than  silver 
nitrate  alone. 

3.  The  Action  of  Antiseptic  Gases  on  the  Urethral  Mucous  Membrane. — 
The  investigations  of  morbid  anatomy  have  estabhshed  that  the  lesions 
produced  in  the  urethral  mucous  membrane  by  the  gonococcus  are  deeply 
seated,  and  not  superficial.  Most  authors  who  have  devoted  their  attention 
to  curing  this  so  rebelhous  affection  have  therefore  sought  for  means  of 
driving  the  drugs  they  used  into  the  substance  of  the  mucous  membrane. 
As  vehicles  for  the  therapeutically  active  substances,  water,  oil,  ointments, 
and  medicated  bougies,  have  been  tried;  the  idea  of  experimenting  with 
gases  was  thus  not  far-fetched. 

One  has  tested  mainly  the  action  of  the  following  gases  in  chronic 
urethritis:  Ozone,  oxygen  (Motz),  formahn  and  iodine  vapours. 

1  Balzer  and  Tansard,  "Traitement  de  la  Blennorragie  Chronique,"  Ann.  Genito- 
Urin.,  May  1,  1906,  p.  641. 


316  GONOKEHEA 

I  have  experimented  in  1903  with  formahn  vapours  in  treating  chronic 
gonorrheal  urethritis.  I  used  a  flask  three-quarters  filled  with  pure  forma- 
lin, and  closed  by  means  of  a  tightly-fitting  stopper  through  which  two 
tubes  passed.  One  of  them  was  connected  with  a  pair  of  bellows,  which 
drove  air  through  the  formalin,  whilst  the  other  one  was  connected  through 
rubber  tubing  with  the  meatus.  As  the  air  bubbled  through  the  formalin, 
formaldehyde  vapours  were  carried  with  it  into  the  urethra.  One  could 
thus  handle  the  gas  as  if  it  were  a  liquid,  and  impregnate  the  mucous  mem- 
brane with  it.  In  most  cases  this  treatment  was  well  borne  and  did  not 
give  rise  to  any  untoward  symptoms.  In  a  few  instances,  however,  it  pro- 
duced a  disagreeable  tingling.  The  therapeutic  results  were  not  encour- 
aging. The  gonococci  disappeared,  certainly,  with  great  rapidity  from  the 
discharge,  which  soon  became  less  white  and  more  fluid,  assuming  finally 
a  serous  character;  but  the  mucous  membrane  showed  signs  of  marked 
irritation,  accompanied  by  a  profuse  serous  discharge.  On  the  whole,  one 
may  say  that  formalin  vapours  produce  a  considerable  oozing  from  the 
mucous  surface  of  the  urethra,  and  that  the  discharge  comes  on  again  as 
soon  as  one  ceases  the  treatment,  and  that  the  gonococci  reappear.  I  have 
therefore  given  up  all  experiments  of  this  kind. 

The  Insufflation  of  Iodine  Vapours  in  the  Treatment  of  Chronic 
Urethritis. — Hamonic^  advocated  the  insufflation  of  iodine  vapours  as  a 
treatment  of  chronic  urethritis  in  the  male. 

His  experiments  on  animals  and  his  chnical  experience  had  shown  him 
that  iodine  vapours  have  no  detrimental  effect  upon  the  urinary  mucous 
surfaces,  and  that  they  are  practically  painless.  He  therefore  devised  a 
special  sound,  which  was  attached  to  a  vessel  containing  metalHc  iodine, 
and  connected  the  two  with  a  pair  of  beflows.  In  this  way  he  drove  iodine 
vapours  into  the  urethra  and  into  the  bladder  by  working  the  bellows  and 
heating  the  vessel.  The  vapours  are  at  first  violet ;  they  then  become  brown, 
and  as  the  iodine  fuses  they  turn  blackish-brown.  The  insufflation  of 
these  black  vapours  into  the  urethra  is  quite  harmless. 

According  to  their  degree  of  concentration,  they  give  rise  to  a  more  or 
less  severe  sensation  of  burning.  Their  immediate  effect  is  to  convert  the 
red  purulent  hquid  into  an  absolutely  transparent  fluid. 

Pfannestihl,  who  had  used  nascent  iodine  for  treating  chest  complaints, 
also  tried  it  on  the  urethra.  He  made  his  patient  take  1  gramme  of  sodium 
iodide  per  day  by  the  mouth,  and  injected  20  drops  of  a  33  per  cent,  solution 
of  hydrogen  peroxide  shortly  afterwards  with  a  syringe  into  the  urethra. 

Others  have  modifled  this  treatment  in  the  foflowing  manner:  They 
commence  by  injecting  with  a  syringe  fitted  to  a  catheter  20  drops  of  a 

^  Hamonic,  "Traitement  de  la  Blennorrhee  par  les  Insufflations  de  Vapeurs  lodees, 
Soc.  de  lied.  Prat.,  June  21,  1888,  and  Journ.  de  Med.  de  Paris,  July  8,  1888. 


THE  TREATMENT  OF  CHRONIC  GONORRHEA  317 

5  per  cent,  solution  of  sodium  iodide  into  the  posterior  urethra.  They  then 
inject  immediately  20  drops  of  a  10  per  cent,  solution  of  hydrogen  peroxide. 

The  treatment  is  painful,  but  the  reaction  is  less  marked  than  with  silver 
nitrate.  The  amount  of  pain  depends  largely  on  the  concentration  of  the 
hydrogen  peroxide. 

A  better  method  of  utilizing  iodine  vapours  is  Kaufmann's,  who  carries 
out  this  treatment  under  the  control  of  the  urethroscope,  and  thus  only 
attacks  the  diseased  spot.  He  paints  the  latter,  working  in  sight,  with  a 
concentrated  solution  of  sodium  iodide,  and  then  apphes  immediately  after- 
wards a  few  drops  of  hydrogen  peroxide  (12  volumes). 

4.  Massage  of  the  Glands  connected  with  the  Urethra. 

To  the  urethra  is  attached  a  well- developed  system  of  glands,  which  con- 
sists of  three  chief  groups : 

1 .  The  glands  of  Littre,  found  mainly  in  the  penile  portion  of  the  anterior 
urethra. 

2.  The  prostate  and  the  seminal  vesicles,  connected  with  the  posterior 
urethra. 

3.  Cowper's  glands,  situated  at  the  bulb. 

These  organs  require  massage  under  certain  conditions. 

1.  Massage  of  Littre'' s  Glands. 

The  inflammatory  secretions  can  be  removed  from  Littre's  glands  by 
massaging  the  penile  urethra,  but,  as  a  rule,  this  method  is  inadequate.  It 
is  only  efficient  when  these  glands  are  in  an  early  stage  of  inflammation. 
After  a  certain  time  the  orifices  become  obstructed  and  the  excretory  ducts 
become  closed.  Indirect  pressure  on  the  bodies  of  the  glands  is  then  useless. 
However,  in  cases  which  are  not  inveterate,  this  method  is  capable  of  giving 
good  results. 

At  which  Stage  should  this  Massage  he  resorted  to  ? — ^According  to  the  rule 
which  we  have  laid  down  above,  the  treatment  of  the  inflamed  glands  of 
Littre  should  not  be  begun  until  the  urine  has  become  clear,  or  at  any  rate 
almost  clear,  and  until  all  pain  on  making  water  or  during  erection  has 
disappeared. 

Technique. — One  begins  with  urethro-vesical  lavage,  using  potassium 
permanganate  or  a  boric  solution  or  oxycyanide  of  mercury,  and  passes 
a  straight  metal  bougie,  taking  the  largest  size  which  the  meatus  admits 
[vide  Fig.  43).  One  then  exerts  methodical  pressure  on  the  lower  circum- 
ference of  the  urethra  with  the  pulp  of  the  first  three  fingers  of  the  right 
hand,  and  stretches  the  organ  by  drawing  it  upwards  with  the  left  hand 
[vide  Fig.  44). 


318  GONOKRHEA 

After  having  carried  the  massage  out  in  this  way  for  a  few  minutes,  one 
withdraws  the  sound  and  asks  the  patient  to  empty  his  bladder,  which,  as 
mentioned,  had  been  filled  with  an  antiseptic  solution. 

If  the  discharge  contains  gonococci,  a  second  urethro- vesical  irrigation 
with  permanganate  should  be  given,  in  order  to  kill  off  those  germs  which 
may  have  been  squeezed  out  of  Littre's  glands. 

This  double  irrigation  method  is  better  than  a  single  irrigation,  because 
in  the  latter  case  the  massage  is  less  comfortable  and  less  efficient.  Moreover, 
the  withdrawal  of  the  sound  is  sometimes  painful,  and  may  be  accompanied 
by  a  httle  bleeding. 

In  1905  Janet^  showed  a  special  instrument  for  massaging  the  glands  of 
the  penile  urethra,  which  consisted  of  a  narrow  metal  tube  presenting  a  hole 
near  its  end.  Its  other  extremity  was  fitted  with  two  taps,  one  of  which 
was  connected  with  a  syringe.  The  tube  was  covered  by  a  rubber  sheath, 
which  presented  a  series  of  ohve-shaped  swelhngs.  By  means  of  the  syringe 
this  cover  could  be  filled  with  water.  On  pressing  the  piston  home  the 
ampoules  were  dilated;  by  letting  it  go  the  olives  contracted  and  drove  the 
piston  back  again.      In  this   way  an   alternate  expansion  and  retraction 


Fig.  144. — Janet's  Urethral  Masseur. 

of  the  ohves  was  obtained.  One  can  also  use  this  instrument  for  sweeping 
the  urethral  mucous  membrane.  The  ohves  are  distended  with  water,  the 
tap  is  closed  when  they  are  filled,  and  the  "  masseur  "  is  moved  to  and  fro. 
Owing  to  the  elasticity  of  the  dilated  rubber  sheath,  this  treatment  is  very 
gentle  and  harmless. 

Dr.  Stordeur^  of  Brussels  has  also  devised  a  special  massage  instrument 
for  Littre's  glands.  It  consists  of  a  straight  hollow  tube  which  is  28  centi- 
metres lorig,  and  carries  at  one  end  a  series  of  twelve  ohves,  which  are  about 
1  centimetre  apart.  The  heel  of  each  ohve  is  directed  towards  the  surgeon, 
and  has  rounded  edges.  The  size  of  these  nobs  is  No.  21,  and  the  last  one 
is  perforated  at  its  basis  by  two  openings,  which  allow  one  to  inject  an 
antiseptic  fiuid  during  the  massage.  The  penis  is  held  firmly,  and  the  instru- 
ment is  introduced;  the  operator  then  moves  it  to  and  fro  in  the  passage. 
The  duration  of  the  massage  depends  on  the  susceptibihty  of  the  patient. 
This  apparatus  certainly  favours  the  evacuation  of  the  glands. 

1  Janet,  Ass.  Frang.  d'UroL,  1905,  p.  296. 

2  Stordeur,  "  Traitement  de  I'Uretrite  Anterieure  par  le  Massage  et  I'Aspiration 
Intra -Uretrale,"  Ann.  d.  I.  Soc.  Beige  d'Urol.,  No.  1,  1910,  p.  43. 


THE  TREATMENT  OF  CHRONIC  GONORRHEA     319 

Intra-urethral  aspiration  of  the  urethral  glands  has  also  been  carried  out 
by  Dr.  Stordeur,^  by  means  of  an  apparatus  consisting  of  a  straight  metal 
sound,  which  is  12  centimetres  long  and  drawn  out.      Its  narrow  end  is 


000003=00.0^00 — !i-'in   I  .  '  I,.  I'   ,     imyi— i 

Fig.  145. — Stordeur's  Urethral  Masseur. 

surrounded  by  a  silver  wire  spiral,  and  terminates  by  an  opening.     Its  size 
corresponds  to  No.  21  or  22. 

Owing  to  its  design,  this  instrument  distributes  the  aspiratory  effect  over 
the  mucous  surface,  and  prevents  the  latter  from  being  aspirated  at  the 


Fig.  146. — Stordeur's  Intra-Urethral  Aspirator. 

level  of  the  opening  in  the  sound.  The  vacuum  is  made  by  means  of  a 
syringe.  At  the  moment  when  the  aspirator  is  withdrawn,  there  is  a 
copious  flow  of  a  clear  or  pink  serous  fluid.  These  aspirations  are  repeated 
every  six  to  eight  days,  according  to  the  tolerance  of  the  patient. 

2.  Vibratory  Massage  of  the  Urethral  Mucous  Memhrane. 

Dr.  Dreuw  of  Berhn^  has  contrived  a  special  system  of  massage  for  the 
urethral  mucous  membrane,  which  is  carried  out  by  means  of  a  special  instru- 
ment of  his  own  invention.  The  vibratory  massage  is  obtained  by  the  issue 
of  a  fluid  under  pressure  through  a  series  of  small  openirigs.  The  hquid 
passes  then  through  larger  holes  to  the  outside.  There  are  two  models — one 
for  the  anterior  urethra,  and  one  for  the  posterior  urethra. 

The  instrument  consists  of  a  double  channel  sound  with  double  walls, 
and  is  covered  with  a  rubber  membrane.  Its  outer  wall  is  perforated  by  a 
number  of  holes  of  the  size  of  a  pin's  head,  placed  at  a  distance  of  1  to  2  centi- 
metres from  each  other.  Between  them  are  other  openings,  which  lead  to 
the  inner  wall.  In  this  way  the  fluid  which  passes  through  the  former  holes 
into  the  urethra  finds  its  way  again  into  the  sound,  and  through  it  to  the 
outside.  This  circulation  sets  up  vibration ;  the  urethral  mucous  membrane 
is  alternately  aspirated  and  distended.  The  greater  the  pressure  of  the 
liquid,  the  greater  is  the  vibratory  effect,  which  is  not  only  noticed  by  the 
patient,  but  can  be  easily  felt  by  the  surgeon  as  he  uses  the  instrument. 

This  interesting  apparatus  may  render  good  services  when  one  wishes  to 
obtain  a  marked  action  on  Littre's  glands  and  Morgagni's  lacunae.  Their 
evacuation  can  be  brought  about  by  this  treatment. 

1  Stordeur,  loc.  cit.,  p.  49.  ^  Dreuw,  Zeits.f.  Urol.,  1910,  vol.  iv. 


320  GONOERHEA 

3.  Massage  of  the  Prostate. 

Indication. — The  prostate  should  be  massaged  in  all  cases  of  chronic 
urethritis.  This  treatment  should  be  resorted  to  as  soon  as  one  has  the 
least  ground  for  suspecting  that  the  posterior  urethra  is  inflamed.  In  cases 
of  this  kind  this  procedure  is  of  value,  because  it  facilitates  the  treatment 
of  the  posterior  urethra  even  when  there  are  no  gross  lesions  in  the  prostate 
which  would  be  easily  palpable  ])er  rectum. 

Contra- Indication. — Prostatic  massage  is  only  contra-indicated  when  the 
gland  is  in  a  state  of  acute  inflammation  or  when  an  epididymo-orchitis  is 
present. 

Technique. — The  patient  makes  water  to  begin  with,  as  a  safeguard 
against  errors.  One  eliminates  in  this  way  all  purulent  debris  originating 
in  the  kidneys  or  the  bladder  which  may  be  suspended  in  the  urine.  One 
then  gives  a  urethro- vesical  irrigation,  and  makes  certain  that  the  hquid  is 
perfectly  clear  when  it  leaves  the  bladder.  This  procedure  eliminates  all 
secretions  which  could  come  from  the  urethra.  One  then  fills  the  bladder 
with  boric  lotion,  and  asks  the  patient  to  assume  the  position  for  massage. 

Two  positions  can  be  made  use  of,  as  described  above  {vide  p.  105,  Fig.  46; 
and  p.  106,  Fig.  47). 

One  of  them  having  been  chosen,  the  surgeon  introduces  his  right  index 
finger  into  the  rectum,  and  massages  the  prostate  by  moving  his  index  from 
above  downwards  and  from  without  inwards  along  the  organ.  By  making 
simultaneously  pressure  on  the  abdomen  with  his  left  hand,  he  can  render 
this  manipulation  easier.  The  pressure  which  should  be  exerted  by  the  finger 
is  variable,  and  must  depend  on  the  state  of  the  prostate  and  on  the  tolerance 
of  the  patient. 

Some  patients  find  the  first  attempts  to  massage  their  prostate  very 
painful,  and  they  may  even  faint.  It  is  therefore  necessary  to  proceed  very 
gently  in  the  beginning.  After  a  while  the  patient  gets  accustomed  to  this 
treatment,  and  stronger  pressure  made  be  made,  and  persevered  with  for  a 
longer  time. 

After  the  massage  the  patient  empties  his  bladder  and  passes  the  boiic 
lotion  into  four  glasses.  In  this  way  the  matter  expressed  from  the  prostate 
can  be  inspected,  and  one  notes  its  character  and  its  amount. 

The  second  position  indicated  is  much  better  than  the  horizontal  one; 
its  advantages  are — • 

1.  The  massage  is  more  efficient,  because  the  index  acts  as  a  powerful 
lever  and  exerts  more  pressure. 

2.  The  liquid  squeezed  out  of  the  prostate  can  be  collected  at  once  in  a 
glass  held  under  the  meatus,  and  thus  an  idea  of  the  amoimt  of  pus  present 
is  easily  obtained. 


THE  TREATMENT  OF  CHRONIC  GONORRHEA     321 

3.  When  the  prostate  is  very  large  or  placed  at  a  higher  level  than 
usually,  this  position  alone  allows  one  to  reach  its  upper  parts.  The  index 
finger  cannot  be  introduced  equally  far  by  any  other  method. 

Comhination  of  Massage  and  Dilatation. — In  certain  cases  of  chronic 
prostatitis,  characterized  by  nodules  which  are  hard  or  painful  on  palpation, 
simple  massage  is  often  inadequate.  It  is  then  best  to  combine  the  massage 
with  dilatation.  The  metal  sound  forms  a  firm  support  against  which  the 
index  can  press  the  sponge-hke  prostate  and  expel  its  contents. 

This  method  is  often  of  considerable  value,  especially  in  fat  subjects,  in 
whom  a  firm  support  cannot  be  obtained  by  pressing  on  the  abdominal  wall. 

Technique. — After  the  patient  has  made  water,  one  fills  his  bladder  with 
boric  lotion,  and  passes  a  large  sound,  preferably  No.  50  G  or  so.  One  then 
massages  the  prostate  whilst  the  sound  is  in  situ. 

The  instrument  is  then  withdrawn  and  the  patient  makes  water.  It  is 
often  astonishing  how  much  epithehal  and  glandular  debris  comes  away 
after  this  intervention. 

Massage  of  the  Prostate  hy  Means  of  Special  Instruments. — Some  prefer  to 
use  special  instruments  for  massaging  the  prostate. 

These  instruments,  of  which  Eeleki's,  shown  in  Fig.  48  on  p.  107,  is 
an  example,  are  sometimes  useful — for  instance,  in  very  stout  people  in 
whom  the  prostate  is  situated  at  such  a  distance  from  the  anus  that  only 
the  tip  of  the  finger  reaches  it,  and  that  it  cannot  be  properly  massaged  with 
the  index.  An  instrument  of  greater  length  is  then  very  welcome.  But 
in  the  vast  majority  of  cases  digital  massage  is  infinitely  preferable.  No 
instrument  can  equal  the  finger  as  far  as  palpation  is  concerned.  The  latter 
alone  can  enable  one  to  feel  the  spot  where  the  inflammation  is  located,  and 
it  gives  a  much  more  complete  evacuation  of  the  gland  pouches. 

Vibratory  Massage  of  the  Prostate. — De  Sard^  has  advocated  vibratory 
massage.  This  treatment  may  be  indicated  in  certain  patients  who  are 
especially  nervous  and  impressionable. 

Electric  Massage  of  the  Prostate. — Others  make  use  of  electricity,  espe- 
cially of  alternating  currents  for  expressing  the  contents  of  the  prostate. 

All  these  instruments  are  composed  of  a  rectal  electrode  which  is  intro- 
duced independently  or  fixed  to  the  finger,  and  an  electrode  which  one  places 
on  the  abdomen  or  on  the  perineum.  Faradic  or  galvanic  currents  can 
be  used. 

1.  Galvanization. — Hogge  of  Liege  prefers  galvanism.  His  negative 
rectal  electrode  consists  of  a  thin  sheet  of  platinum  which  is  covered  with 
chamois  leather  and  carried  on  a  rubber  finger-stall.  The  positive  electrode 
consists  of  a  pad  which  is  apphed  to  the  perineum.  A  current  of  5  to  10  milh- 
amperes  is  passed  for  five  to  ten  minutes. 

1  De  Sard,  Ass.  Franc.  d'Urol,  1906,  p.  309. 

21 


322  GONORRHEA 

2.  Faradization. — Courtade  uses  an  apparatus  which  consists  of  a  metal 
stem,  a  rubber  finger-stall,  and  a  metal  pad.  The  stem  is  flat  and  flexible. 
It  carries  a  thin  sheet  of  platinum  at  one  end,  whilst  its  other  extremity  is 
connected  with  the  negative  pole.  The  rubber  finger  is  double,  and  perfor- 
ated at  its  end  by  a  number  of  httle  holes,  through  which  the  electricity 
diffuses.  It  is  placed  in  contact  with  the  rectal  mucous  membrane.  The 
metal  stem  is  interposed  between  the  two  fingers  and  the  sheet  of  platinum. 
The  metal  plate  is  put  on  the  abdomen  and  connected  with  the  positive  pole. 

Instead  of  this  somewhat  complicated  apparatus,  a  simple  electrode  con- 
sisting of  a  piece  of  wood  or  ebonite  may  be  used.  It  is  apphed  directly  to 
the  prostate,  and  does  not  require  to  be  guided  by  the  finger. 

In  any  case  this  type  of  massage  is  much  too  comphcated,  and  should  be 
reserved  for  special  occasions — for  instance,  for  patients  who  are  nervous 
and  impressionable. 

4.  The  Massage  of  the  Seminal  Vesicles. 

The  seminal  vesicles  are  massaged  in  the  same  way  as  the  prostate,  and 
the  technique  is  similar. 

Indications. — This  treatment  is  indicated  whenever  the  seminal  vesicles 
are  in  a  state  of  chronic  inflammation.     The  diagnosis  is  made  by  palpating  " 
these  organs  -per  rectum,  as  described  on  p.  110  and  in  Chapter  IX. 

It  is  always  necessary  to  examine  the  seminal  vesicles  in  the  course  of 
an  attack  of  gonorrhea,  and,  as  the  symptoms  of  their  infections  are  often 
vague  and  obscure,  it  should  be  a  matter  of  routine  to  explore  them. 

Technique. — The  technique  is  here  practically  the  same  as  in  the  case  of 
the  prostate.  It  is,  however,  necessary  to  place  the  patient  in  the  position 
described  on  p.  110,  as  it  is  impossible  to  reach  the  seminal  vesicles  properly 
in  the  horizontal  position. 

In  order  to  ascertain  if  the  vesicles  can  be  reached  easily  per  rectum, 
Feleki  has  measured  the  distance  between  the  anus  and  these  organs  in 
thirty- two  corpses  of  subjects  who  had  died  between  the  ages  of  twenty-one 
and  sixty-four.  In  four  cases  he  found  a  minimum  of  5  centimetres  as  dis- 
tance between  the  anus  and  the  lower  part  of  the  prostate;  the  maximum 
was  8  centimetres,  and  was  noted  twice;  the  average  of  this  measurement  is 
therefore  6'3  centimetres.  The  distance  from  the  anus  to  the  upper  part  of 
the  prostate  is  9-2  centimetres  on  the  average  ;  a  minimum  of  7-5  centi- 
metres was  recorded  three  times,  and  a  maximum  of  13  centimetres  once. 

The  distance  from  the  anus  to  the  upper  part  of  the  seminal  vesicles  varies 
between  9  centimetres  (minimum)  and  16"5  centimetres  (maximum),  the 
average  being  12-5  centimetres.  These  measurements  were  made  with 
empty  rectum  and  bladder. 

Lewin  and  Bohm  found  5  to  7  centimetres  as  average  distance  between 


THE  TREATMENT  OF  CHRONIC  GONORRHEA     323 

the  anus  and  the  lower  end  of  the  seminal  vesicles,  and  8  to  12  centimetres  as 
average  distance  between  the  anus  and  the  upper  end  of  the  seminal  vesicles. 

It  is  thus  very  difficult  to  feel  the  seminal  vesicles  with  the  index  finger, 
which  measures  as  a  rule  7  or  8  centimetres.  As  in  the  case  of  gynecological 
examinations,  the  "  touch  "  and  the  experience  of  the  surgeon  are  the 
important  factors  in  the  palpation  of  the  seminal  vesicles,  and  not  the  length 
of  his  finger. 

For  the  expression  of  the  seminal  vesicles,  the  index  should  be  introduced 
as  far  as  possible  beyond  the  prostate,  and  gradually  be  brought  down  to  that 
gland.  In  very  many  cases  the  vesicles  can  be  expressed  and  emptied  into 
the  urethra  in  this  fashion. 

The  secretions  are  collected  in  a  glass,  and  should  be  examined  micro- 
scopically in  a  manner  similar  to  that  used  for  the  prostatic  fluid. 

The  Normal  Vesicular  Contents. — The  contents  of  the  seminal  vesicles 
have  been  studied  for  many  years,  and  all  the  findings  have  been  compiled 
by  Guelhot,  as  far  as  they  are  laid  down  in  the  hterature.  The  vesicular 
secretion  is  an  odourless,  mucous,  and  viscous  fluid,  which  is  somewhat 
sticky  and  of  a  relatively  considerable  density.  Its  reaction  is  alkaUne, 
and  its  colour  is  greyish,  except  in  very  old  men,  in  whom  it  is  brownish. 
Under  the  microscope  one  often  sees  transparent  round  bodies,  which  Robin 
termed  "  sympexion."  Their  purpose  and  their  chemical  constitution  are 
not  completely  known.  They  dissolve  in  acetic  acid,  and  are  often  so  per- 
fectly round  and  transparent  that  they  are  apt  to  be  mistaken  for  air- bubbles. 
One  also  finds  a  few  spermatozoa  and  httle  mucous  droplets,  which  resemble 
amorphous  phosphatic  precipitates. 

The  presence  of  leucocytes  and  red  blood-cells  in  the  secretions  of  the 
seminal  vesicles  is  a  pathological  finding.  Schlaginweit  has  described  a 
phenomenon  which  appears  to  be  characteristic  of  the  vesicular  secretion: 
A  drop  placed  in  water  sinks  vertically  to  the  bottom,  but  if  one  adds  a  drop 
of  prostatic  secretion  to  the  product  of  the  vesicle,  the  latter  loses  its  vis- 
cosity and  becomes  miscible  with  water. 

The  Vesicular  Contents  in  Disease. — In  chronic  spermato-cystitis  one  is 
apt  to  find  pus,  blood,  and  bacteria  in  the  secretion,  which  can  be  examined 
either  immediately,  in  the  fresh  state,  or  after  it  has  been  dried  and  stained. 
The  former  method  is  usually  sufficient  for  clearing  up  the  diagnosis.  Before 
these  histological  researches  are  undertaken,  it  is  necessary  to  clean  the 
glans  and  to  wash  the  whole  urethra  with  an  antiseptic  solution.  It  is  in- 
teresting to  note  that  expression  of  the  vesicles  often  yields  semisoUd 
masses  which  are  moulded  according  to  the  outhnes  of  the  culs-de-sac  of 
the  vesicle.  The  fragments  thus  obtained  assume  most  curious  shapes, 
and  are  of  great  diagnostic  importance,  as  they  reveal  their  origin  and 
form  a  good  basis  for  microscopic  and  bacteriological  research. 


324  GONOKKHEA 

One  should  also  examine  the  whole  product  of  vesicular  expression 
which  is  passed  as  the  patient  empties  the  boric  lotion  with  which  his  bladder 
had  been  filled.  It  is  a  great  mistake  to  think  that  all  the  vesicular  contents 
come  away  at  the  first  micturition.  In  many  cases  the  subsequent  micturi- 
tions contain  a  certain  amount  of  the  products  of  the  diseased  vesicles,  and 
one  should  notify  the  patient  of  this  fact.  The  vesicular  contents  wait,  so 
to  say,  in  the  ejaculatory  ducts,  and  only  leave  them  gradually  under  the 
influence  of  a  movement — micturition,  walking,  etc. 

There  are  cases  in  which  the  ejaculatory  ducts  are  in  a  state  of 
chronic  inflammation  and  have  become  obliterated.  All  massage,  how- 
ever energetic,  is  then  useless,  and  the  vesicular  pouch  cannot  be 
emptied  despite  all  efforts.  This  is  a  most  disagreeable  complication;  the 
urine  remains  turbid  for  a  very  long  time,  and  one's  means  of  action  are 
hmited.^ 

The  massage  should  always  be  carried  out  with  great  care,  as  has  already 
been  pointed  out,  because  an  excessively  active  treatment  may  be  followed 
by  attacks  of  fever  and  by  epididymitis. 

One  can  easily  understand  that  the  thin-walled  vesicle  may  rupture 
under  the  effect  of  violence,  and  that  in  this  way  its  purulent  contents  may 
reach  the  peritoneum  and  lead  to  a  calamity. 

Both  prostatic  and  spermato- cystic  massage  should  not  be  continued 
for  too  long  a  period.  It  is  certain  that  they  may  under  that  condition  lead 
to  debility  and  exhaustion,  characterized  by  extreme  weakness.  Very 
nervous  patients  complain  chiefly  of  being  "  hght-headed  "  after  the  mas- 
sage. In  the  case  of  a  patient  who  was  suffering  from  prostatitis  and  an 
inflammation  of  his  left  seminal  vesicle,  massage  constantly  lead  to  the 
evacuation  of  pus;  but  after  it  had  been  carried  out  for  one  and  a  half 
months,  the  patient  became  so  anemic  and  worn  out  that  it  had  to  be  in- 
terrupted and  a  period  of  rest  in  the  country  became  necessary. 

A  series  of  instruments  have  been  advocated  for  massaging  the  seminal 
vesicles.  Keyes,  for  instance,  devised  an  instrument  consisting  of  two 
parts,  which  is  introduced  empty  into  the  rectum.  One  then  inflates  the 
two  halves,  which,  as  they  distend,  compress  the  seminal  vesicles  and  ex- 
press their  contents.  As  a  rule,  this  apparatus  is  most  uncomfortable  for 
the  patients;  moreover,  one  cannot  regulate  the  pressure  easily;  and,  thirdly, 
it  is  almost  impossible  to  tell  if  the  instrument  is  in  its  proper  position  and 
if  it  fulfils  its  purpose. 

Feleki  has  also  invented  a  special  instrument.  Here  again  it  is  difficult 
to  make  out  if  the  apparatus  is  in  its  right  place  and  if  the  pressure  is  correct. 
Feleki  himself  realized  its  drawbacks,  and  wished  to  see  it  used  only  in 
cases  in  which  the  tenderness  or  the  enlargement  of  the  prostate  made  it 

1  Vide  Chapter  IX.,  Spermato -Cystitis  (A.  F.). 


THE  TEEATMENT  OF  CHRONIC  GONORRHEA     325 

impossible  for  the  finger  to  touch  all  its  parts,  and  in  stout  people  in  whom 
the  seminal  vesicles  are  beyond  reach. 

Eastman's  apparatus  is  based  on  a  different  principle.  As  the  human 
finger  is  too  short  to  reach  the  upper  end  of  the  seminal  vesicle,  he  devised 
a  nickel-plated  metal  thimble  to  be  worn  on  the  index,  which  is  thus 
lengthened  by  5  centimetres.  He  invented  several  different  patterns,  a 
flat  and  a  bulbous  one.  These  instruments  are  occasionally  useful  in 
chronic  spermato-cystitis. 

5.  The  Massage  of  Cowpers  Glands. 

Indications. — As  Cowper's  glands  are  frequently  implicated  in  the 
course  of  an  attack  of  gonorrhea,  and  as  their  inflammation  does  not  usually 
give  rise  to  characteristic  symptoms,  they  should  always  be  explored. 

Massage  of  Cowper's  glands  is  indicated  whenever  pressure  on  one  of 
them  is  followed  by  a  purulent  discharge  from  the  urethra.  It  is  contra - 
indicated  when  no  pus  can  be  squeezed  out  of  these  glands. 

Technique. — One  lets  the  patient  make  water  to  begin  with,  and  fills 
his  bladder  by  means  of  a  urethro- vesical  irrigation  with  a  1 :  4,000  solution 
of  oxy cyanide  of  mercury.  The  patient  then  lies  down  on  a  couch  with 
his  thighs  and  legs  semiflexed,  the  heels  being  together  and  the  knees 
apart.  The  pelvis  is  raised  by  means  of  a  cushion,  and  the  scrotum  is 
lifted  up. 

The  massage  of  Cowper's  glands  is  then  carried  out  with  two  fingers  in 
a  manner  similar  to  the  bidigital  palpation  of  these  organs  (vide  p.  102  and 
Fig.  45).  The  index  of  the  right  hand  is  passed  into  the  anus,  the  palmar 
surface  pointing  forwards.  Beyond  the  sphincter,  the  finger  hooks 
forwards  until  it  reaches  the  bulb  of  the  urethra.  Simultaneous  pressure 
is  made  with  the  right  thumb  on  the  perineum  to  one  side  of  the  median 
raphe. 

In  this  manner  Cowper's  gland  is  felt  between  the  index  in  the  rectum 
and  the  thumb  on  the  perineum.  When  the  gland  is  inflamed,  it  may  be 
palpable  as  a  Httle  roundish  mass  of  the  size  of  a  pea.  One  squeezes  it 
energetically,  avoiding  to  make  pressure  on  the  prostate,  and  then  asks  the 
patient  to  make  water  into  several  glasses. 

The  first  glass  contains  the  secretions  removed  from  Cowper's  gland  by 
massage;  they  are  centrifuged  and  examined  under  the  microscope. 

In  certain  cases  this  method  fails.  Nothing  can  be  expressed  from  the 
diseased  gland,  and  the  treatment  merely  gives  rise  to  sharp  pains.  One  is 
then  confronted  with  an  obliteration  of  the  gland  duct,  and  other  measures, 
preferably  excision  of  the  gland  through  an  incision  in  the  perineum,  be- 
come necessary  {vide  pp.  193  and  194) 


326  GONORRHEA 

5.  The  Dilatation  Treatment  of  Chronic  Urethritis. 

Dilatation  of  the  urethra  is  certainly  the  best  method  of  treating  and 
curing  chronic  urethritis.  There  are  but  few  inveterate  cases  which  are 
refractory  against  this  therapy.  However,  it  is  only  successful  if  the  dilatc- 
tion  is  carried  out  in  a  very  powerfid  manner  and  if  it  is  applied  with  accuracy 
to  the  diseased  focus. 

Dilatation  should  be  resorted  to.  firstly,  in  those  cases  in  which  the  ex- 
ploratory olive  has  revealed  the  presence  of  a  stricture;  but  it  should  also 
be  used — and  this  fact  does  not  seem  to  be  generally  known — in  those  cases 
of  chronic  urethritis  in  which  the  lesions  consist  of  locaUzed  patches  within 
the  anterior  urethra,  which  escape  detection  as  long  as  the  ordinary  ex- 
ploratory methods  are  used.  As  such  we  mention  the  lacunae  of  Morgagni 
and  glands  of  Littre,  with  everted,  red,  and  inflamed  borders,  which  can  only 
be  diagnosed  with  the  aid  of  the  urethroscope. 

One  need  only  to  have  seen  these  lesions  once  in  order  to  be  able  to  under- 
stand that  irrigations  and  instillations  cannot  have  any  action  on  them 
The  liquids  introduced  remain  on  the  surface  of  the  mucous  membrane,  and 
cannot  reach  the  deeper  parts.     These  deeply-seated  inflammations  require 
a  mechanical  treatment. 

Dilatation  alone  can  free  all  the  glands  of  Littre  of  their  contents; 
it  flattens  out  the  lacunae  of  Morgagni  and  expresses  them  Hke  a 
sponge. 

As  far  back  as  1844,  Benique  made  the  observation  that  he  could  curt 
chronic  urethritis  by  means  of  dilatation.  Alphonse  Guerin,  Voillemier, 
Desormeaux,  and  Thompson,  followed  his  example  and  advocated  this 
therapeutic  measure.  Otis  made  a  chnical  study  of  this  question,  and  his 
writings  on  wide  strictures  marked  a  considerable  advance.  To  Oberlander 
and  his  pupils  belongs  the  credit  of  having  definitely  estabUshed  the  im- 
'portance  of  dilatation  as  a  treatment  of  chronic  urethritis. 

We  know  that  the  rebelhousness  of  certain  cases  of  chronic  urethritis 
resides  chiefly  in  the  presence  of  patches  of  subepitheHal  cellular  infiltra- 
tion, which  gradually  become  converted  into  fibrous  tissue,  and  ultimately 
give  rise  to  strictures.  It  is  only  by  far-pushed  dilatation  that  these 
foci  can  be  reached  and  annihilated,  as  the  urethral  mucosa  is  being 
distended. 

"The  normal  parts  of  the  urethra  are  very  elastic  and  resistant  owing 
to  their  wealth  in  elastic  fibres.  Dilatation  is  therefore  merely  a  gymnastic 
movement  for  them;  whilst  the  infiltration  areas,  however  small  they  may 
be,  are  void  of  elasticity  and  give  way  by  tearing.  A  new  inflammation  is 
thus  set  up,  which  leads  to  the  disappearance  of  the  old  inflammation  and 
favours  the  resorption  of  the  elements  of  the  shattered  focus.     By  means 


THE  TREATMENT  OF  CHRONIC  GONORRHEA      327 

of  the  urethroscope  one  can  follow  step  by  step  this  process  until  the  cure 
is  obtained,  which  is  characterized  by  the  formation  of  a  perfectly  smooth 
and  inoffensive  scar. 

"As  these  cellular  foci  are  being  made  to  undergo  resorption  and  to 
vanish,  the  symptoms  of  chronic  urethritis  usually  disappear,  and  the  urine 
becomes  free  from  filaments."^ 

When  should  one  begin  these  Dilatations  ? — ^This  treatment  should  not 
be  commenced  until  the  discharge  has  become  insignificant  and  until  the 
urine  contained  in  the  first  glass  has  become  clear. 

Should  the  presence  of  the  gonococcus  in  the  urethra  be  regarded  as  a 
contra-indication  ? 

Janet  answers  this  question  in  the  affirmative.  According  to  him,  no 
instrument  should  be  passed  into  the  urethra  as  long  as  Neisser's  organism 
inhabits  the  passage. 

Vigneron,  whose  opinion  we  endorse,  is  less  strict.  As  long  as  the  acute 
stage  lasts,  and  as  long  as  the  urine  in  the  first  glass  is  turbid  and  micturition 
is  accompanied  by  pain,  it  would  be  reckless  to  introduce  any  instrument 
into  the  urethra;  but  when  the  urine  has  become  clear,  after  a  well-directed 
treatment,  although  it  may  contain  some  filaments,  we  think  it  advisable 
to  complete  our  examination  of  the  urethra,  and  we  do  not  hesitate  to  use 
instruments  with  certain  precautions. 

When  two  or  three  series  of  urethro- vesical  irrigations  have  proved  a 
failure,  when  one  is  certain  that  the  disease  is  not  prolonged  by  lesions  in 
the  prostate  or  in  the  para-urethral  ducts,  then  it  is  necessary  to  explore 
the  urethra.  One  naturally  chooses  a  time  in  which  the  urine  has  been 
rendered  clear  by  permanganate  irrigations.  One  examines  the  whole 
passage  carefully  with  an  olivary  bougie,  and  if  one's  attention  is  called  to 
a  stricture  by  the  heel  of  the  olive  as  it  is  withdrawn,  one  should  not  hesi- 
tate to  resort  to  gradual  dilatation  with  curved  metal  sounds,  combining 
this  treatment  with  permanganate  irrigations.  If  the  stricture  is  in  the 
penile  urethra,  straight  sounds  are  sufficient,  and  in  this  case  there  is  no 
accident  to  be  feared. 

Preparation  of  the  Patient.— Very  often  patients  who  require  dilatation 
treatment,  suffer  from  a  congenital  atresia  of  the  meatus. 

As  dilatations  are  all-important  in  the  treatment  of  chronic  urethritis, 
it  becomes  necessary  to  widen  the  meatus  either  temporarily  or  permanently 
in  cases  of  this  kind. 

1.  Temporary  Dilatation  of  the  Meatus. — Kelly  of  Baltimore  has  in- 
vented a  special  instrument  which  enables  one  to  stretch  the  meatus  for  a 
short  time.  The  use  of  this  apparatus  is  very  simple;  it  is  introduced  into 
the  meatus  and  gradually  pressed  farther  and  farther  into  the  urethra. 

1  Menahem  Hodara,  Ann.  d.  Hal.  d.  Org.  Genito-Urin.,  August,  1895,  pp.  704,  705. 


328 


GONOEEHEA 


When  only  one  or  two  dilatations  are  contemplated,  this  procedure  may  be 
serviceable;  but  if  one  wishes  to  carry  out  a  prolonged  dilatation  treatment, 
meatotomy  is  infinitely  preferable. 

2.  Meatotomy. — Under  normal  conditions,  the  meatus  and  the  neck  of 
the  fossa  navicularis  are  the  narrowest  and  least  extensible  parts  of  the 
urethra;  it  is  therefore  indicated  to  incise  them  when  they  prevent  instru- 
ments from  passing.  This  simple  little  operation  can  be  performed  with  a 
special  meatotome  or  with  the  galvano-cautery. 


Fig.  147. — Kelly's  Dilator  for  the  Urethral  Meatus. 

The  meatotome  allows  one  to  operate  very  rapidly  in  a  few  seconds,  but 
its  use  is  often  followed  by  troublesome  bleeding.  The  intervention  is 
carried  out  in  the  following  way:  Once  the  parts  have  been  cleansed,  the 
instrument  is  closed  and  passed  into  the  meatus  for  a  distance  of  3  centi- 
metres or  so.  One  then  presses  on  the  lever;  the  blade  is  thus  made  to 
project  inside  the  urethra,  and  as  it  is  withdrawn  it  divides  the  tissues. 
Care  should  be  taken  that  the  knife  is  on  the  under- surface,  that  it  is  made 
to  project  sufficiently,  and  that  the  cutting  is  done  along  the  middle  line. 
If  the  latter  be  followed  accurately  the  bleeding  will  be  insignificant.  If 
the  hemorrhage  is  troublesome,  a  httle  swab  soaked  in  adrenaUn  may  be 
inserted  with  advantage  between  the  lips  of  the  wound;  it  stops  all  bleeding, 


Fig.  148. — Meatotome. 

and  a  light  dressing  is  then  applied.  If  the  patient  has  a  long  prepuce, 
the  latter  can  be  made  use  of  for  holding  the  wool.  If  the  prepuce  is 
too  short  or  if  the  patient  is  circumcised,  the  meatus  is  covered  by  a 
thick  pad  of  wool,  which  is  kept  in  position  by  means  of  a  bandage. 
On  the  following  days  the  patient  should  separate  the  edges  of  his  wound 
repeatedly,  as  the  Hps  have  a  marked  tendency  to  stick  together  and  to 
heal  rapidly. 

The  use  of  the  electric  cautery  obviates  any  bleeding;  during  and  after 
this  httle  operation  there  is  hardly  a  drop  of  blood.  The  operation  itself 
is,  however,  more  compHcated  and  more  difficult.  One  anesthetizes,  to  begin 
with,  the  lower  part  of  the  meatus  by  injecting  a  few  drops  of  a  1  per  cent, 
stovain  solution  subcutaneously.  One  then  passes  a  small  speculum  in 
order  to  separate  the  Hps  of  the  meatus,  and  divides  the  lower  wall  along 


THE  TREATMENT  OF  CHRONIC  GONORRHEA 


329 


the  middle  line  with  the  cautery.  The  section  should  include  not  only  the 
exterior  of  the  meatus — this  would  be  an  incomplete  operation — but  also 
the  inner  wall  of  the  urethra  for  a  length  of  a  few  milUmetres. 

Whatever  method  one  may  employ,  one  can  always  ascertain  immediately 
if  the  meatotomy  has  been  successful  by  inserting  a  big  sound,  58  or  60  G. 
This  instrument  should  enter  the  passage  without  any  difficulty. 

General  Rules  for  Dilating  the  Urethra.— Broadly  speaking,  all  dilata- 
tion treatment  should  be  begun  with  curved  metal  sounds,  unless  very 
tight  strictures  are  present  which  allow  only  the  small  ohves  to  pass. 
For  cases  of  that  kind  small  bougies  are  indicated  until  No.  12  is  reached; 
one  then  continues  with  the  ordinary  curved  sounds. 


Fig.  149. — First  Step  in  the  Introduction  of  a  Curved  Sound. 

The  instrument  is  entering  the  meatus;  its  concavity  is  pointing  towards  the  right 

inguinal  fold. 

The  size  of  the  first  sound  which  should  be  passed  is  indicated  by  the 
oh  vary  exploratory  bougie.  If,  for  instance,  an  ohve  No.  15  gave  a  Httle 
jerk  at  the  perineum,  one  chooses  a  sound  No.  30  G;  in  the  same  way,  if  an 
olive  No.  16  revealed  the  presence  of  a  shght  constriction  in  the  penile 
portion,  one  begins  with  a  sound  No.  32  G. 


330 


GONOERHEA 


The  safest  plan  to  adopt  is  the  following: 

1.  The  patient  makes  water. 

2.  His  bladder  is  filled  from  an  irrigator  with  a  solution  of  boric  acid  or 
of  1 :  4,000  oxycyanide  of  mercury. 

3.  Three  metal  sounds  are  passed. 

4.  The    patient    relieves    his    bladder    of    the    oxycyanide    or    boric 
solution. 

After  bougies   and   curved    metal    sounds    have   been   passed   up   to 
No.  60  Q,  the  patient  should  be  urethroscoped  in  order  to  see  if  any  patches 


Fig.  150. — Second  Step  in  the  Introdtjction  of  a  Cueved  Sound. 
The  instrument  is  parallel  with  the  middle  line. 


of  hard  infiltration  are  left,  which  require  further  dilatations.  When  this 
is  necessary,  the  instruments  of  Oberlander  and  Kollmann  are  used.  In 
the  same  way  as  a  topic  should  be  apphed  to  a  wound,  dilatation  should 
only  affect  the  diseased  area,  and  the  instruments  just  mentioned  allow  one 
to  carry  out  this  local  therapy  with  great  precision. 

Gradual  and  methodical  dilatation  treatment  enables  one  to  deal  effectu- 
ally with  chronic  discharges  from  the  urethra  in  the  great  majority  of  cases. 

Dilatation  of  the  Urethra  with  Curved  Metal  Sounds. — The  surgeon 
stands  to  the  right  of  the  patient,  seizes  his  penis  with  the  left  hand,  and 
draws  it  towards  the  right  inguinal  fold.     The  well- lubricated  sound  is  held 


THE  TREATMENT  OF  CHRONIC  GONORRHEA 


331 


in  the  right  hand  and  presented  to  the  meatus,  care  being  taken  to  keep  its 
concavity  directed  towards  the  right  inguinal  fold  (Fig.  149). 

The  instrument  is  then  made  to  advance  along  the  penile  and  scrotal 
portions.  As  it  passes  on,  the  left  hand  brings  the  penis  gradually  towards 
the  abdomen;  the  instrument  is  then  parallel  with  the  middle  hne  at  the 
moment  when  it  is  about  to  enter  the  perineal  portion  (Fig.  150). 


Fig.  151. — Third  Step  in  the  Introduction  of  a  Curved  Sound. 

The  left  hand  pulls  vertically  on  the  penis.     The  right  hand  holds  the  sound  without 

pushing  it. 

At  this  stage  the  left  hand  makes  a  httle  traction  on  the  penis,  whilst 
the  right  hand  maintains  the  sound  in  its  place ;  it  then  puUs  the  penis  over 
the  sound  and  brings  it  to  a  right  angle  with  the  body  (Fig.  151). 

This  traction  with  the  left  hand  should  be  continued  until  the  right 
hand,  which  supports  the  sound  without  pushing  it,  feels  that  the  point  is 
entering  the  membranous  portion. 

The  left  hand  is  then  taken  away  from  the  penis,  and  is  placed  flat  on 
the  suprapubic  region,  pressing  it  and  the  root  of  the  penis  downwards. 
At  the  same  time  the  right  hand  merely  supports  the  instrument  whilst  it 


y 


332 


GONOERHEA 


dives  into  the  bladder,  describing  a  curve.  The  entry  into  the  deeper  por- 
tions of  the  urethra  and  into  the  bladder  takes  place  almost  automatically 
in  this  fashion.  It  is  unnecessary  to  push  the  instrument  into  the  bladder 
with  force  (Fig.  152). 

How  many  Sounds  should  he  'passed  at  Each  Visit  ? — ^As  a  rule  three  sounds 
are  passed  at  each  visit.  One  begins  with  the  highest  number  passed  at 
the  last  visit,  and  introduces  subsequently  the  two  next  higher  numbers. 

How  Long  should  the  Sound  he  left  in  Situ? — In  most  cases  it  is  sufficient  to 
pass  the  instruments,  and  there  is  no  need  to  leave  them  inside  the  urethra 
for  any  length  of  time.  However,  if  their  introduction  is  at  all  uncom- 
fortable— i.e.,  when  they  are  so  large  that  they  distend  the  urethral  mucous 


Fig.  152. — Fgtjbth  Step  ik  the  Intbodxjction  of  a  Curved  Sound. 

The  left  hand  draws  the  root  of  the  penis  downwards,  whilst  the  right  hand  merely 
supports  the  instrument  as  it  goes  through  its  dcwTiward  movement. 

membrane — then  it  is  well  to  leave  them  for  a  while  until  the  patient 
feels  no  longer  any  pain.  In  this  way  dilatation  produces  its  full  effect.  It 
should  never  be  forcible,  and  it  is  only  of  advantage  if  it  causes  no  discomfort. 
What  Intervals  should  he  allowed  to  elapse  hetween  the  Visits  ? — The  in- 
tervals required  between  the  various  visits  are  variable.  If  the  dilatation 
has  not  been  followed  by  the  sHghtest  trace  of  bleeding,  and  if  it  has  been 
painless,  one  can  begin  again  in  two  days'  time,  and  dilate  three  times  per 
week.  If,  on  the  other  hand,  the  intervention  has  been  painful,  and  especially 
if  there  has  been  bleeding  after  the  passing  of  the  sounds,  then  one  should 
wait  longer,  and  dilate  only  once  every  four  or  five  days,  or  even  only  every 
eight  or  ten  days. 


THE  TREATMENT  OF  CHRONIC  GONORRHEA     333 

The  Use  of  Filiform  Bougies. — The  introduction  of  metal  sounds  is  often 
rendered  difficult  by  the  fact  that  they  have  to  pass  an  excentric  stricture. 
When  the  lumen  of  the  stricture  and  that  of  the  urethra  are  not  in  the  same 
line,  the  instrument  is  caught,  and  some  bleeding  usually  takes  place.  The 
best  way  of  dealing  with  these  cases  is  to  use  a  catheter  guide,  or  ferret, 
which  is  fitted  with  a  screw  and  can  be  affixed  to  the  end  of  the  sound. 


Fig.  153. — Filiform  Bougie. 

This  instrument  is  screwed  on  to  the  top  of  the  sound,  and  is  passed  first. 
It  paves  the  way,  as  it  were,  for  the  latter. 

The  technique  is  very  simple:  The  guide  is  introduced;  one  then  screws 
the  sound  on  to  its  end  and  passes  it  according  to  the  rules.  The  latter 
then  enters  with  the  utmost  ease;  the  guide  renders  it  impossible  to  make 
a  false  passage,  and  curls  up,  when  it  has  been  pushed  into  the  bladder, 
without  ever  doing  the  slightest  harm. 

On  Dilatation  with  Four-Bladed  Dilators. — The  four-bladed  dilators 
should  only  be  used  secondarily,  after  the  urethra  has  been  dilated  with 


Figs.  154-156. — Different  Models  of  OberlInder's  Straight  Two-Bladed 

Dilator. 

curved  metal  sounds,  because  their  action  is  a  different  one.  As  a  rule,  the 
curved  sounds  do  not  stretch  the  urethral  mucous  membrane  sufficiently; 
for  instance,  if  there  is  a  constriction  in  the  region  of  the  perineum.  No.  60  G 
sound  is  inadequate.  The  widest  part  of  the  urethra  is  the  bulb,  and  the 
narrowest  is  the  balanic  portion.     As  these  metal  sounds  are  of  a  uniform 


334  GONORRHEA 

diameter,  the  dilatation  produced  by  the  instrument  will  be  considerable  in 
and  efl&cient  in  the  penile  portion  when  the  instrument  barely  touches  the 
walls  of  the  perineal  portion.  One  therefore  requires  special  instruments 
with  which  the  diseased  area  can  be  accurately  dilated,  and  which  are  more 
in  agreement  with  the  anatomy  of  the  urethra.  Professor  Oberlander  of 
Dresden  and  Professor  Kollmann  of  Leipzig  have  invented  such  dilators, 
which  are  mostly  two-bladed  or  four-bladed.  They  are  introduced  closed, 
and  their  branches  are  separated  by  turning  a  large  terminal  screw,  once 
they  are  in  the  urethra.  The  older  models  had  to  be  covered  with  a  rubber 
sheath,  as  without  this  precaution  the  urethral  mucous  membrane  was  apt 
to  be  nipped  when  one  closed  the  instrument.  The  newer  models  no  longer 
require  the  rubber  sheath.^  There  are  a  great  number  of  different  patterns. 
Those  intended  for  the  anterior  urethra  are  straight,  whilst  those  for  the 
posterior  are  curved.  Some  are  designed  in  such  a  way  that  their  action 
is  confined  to  one  special  portion  of  the  urethra.  Some  are  thinner  than 
others,  corresponding  when  closed  to  a  No.  20,  and  have  weaker  blades. 
They  are  especially  suitable  for  cases  with  a  small  meatus  and  for  those  in 
which  only  slight  dilatation  is  desired.     Others,  again,  are  very  powerful. 


nisL:i:i;:i.i:jii!]iiii;L 


■' >'"i'!i'-'ii"i'-'i"'-i-i'-J^'--aii;Li^i..iu.i-iu-ii„':i,,.i-i....„. 


Fig.  157. — Sheath  for  Kollmann' s  Dilator. 

and  cannot  be  passed  unless  the  meatus  is  wide;  they  are  chiefly  intended 
for  urethree  which  contain  much  fibrous  tissue  and  require  a  certain  amount 
of  force. 

Description  of  Kollmann's  Four-Bladed  Dilator. — The  older  models  of 
Kollmann's  four-bladed  dilator  required  to  be  covered  with  a  rubber  sheath 
in  order  to  protect  the  urethral  mucous  membrane  against  being  pinched 
when  one  closes  the  instrument.  With  the  recent  models  this  is  no  longer 
necessary,  as  the  blades  are  grooved  and  arranged  in  such  a  way  that  they 
cannot  possibly  catch  the  mucosa  when  they  come  together.  A  huge  screw 
on  the  end  of  the  handle,  which  can  be  manipulated  with  great  ease,  allows 
one  to  separate  the  blades  gradually  and  slowly ;  in  this  way  powerful  dilata- 
tion can  be  made.  The  degree  of  dilatation  is  indicated  by  a  hand,  which 
moves  on  a  graduated  disc. 

The  dilatations  carried  out  with  this  instrument  are  of  the  utmost  value 
if  they  be  done  with  caution  and  method;  they  should  be  done  very  slowly 
and  be  gradually  increased.  Their  chief  object  is  to  render  the  urethral 
mucous  membrane  supple  again,  not  only  in  the  superficial  parts  of  the 
epithelium,  but  also  in  the  deeper  parts  of  the  derm.     The  stretching  carried 

1  Kollmann,  "  Remarques  sur  les  Dilatateurs  a  Quatre  Branches  de  Construction 
Perfectionnee,"  Ann.  Genito-Urin.,  1903,  p.  1150. 


THE  TREATMENT  OF  CHRONIC  GONORRHEA 


335 


out  is  comparable  with  similar  actions  on  tissues  or  on  rubber;  if  one  stretches 
abruptly  with  a  certain  amount  of  force,  one  produces  tears  and  fissures. 
Such  solutions  of  continuity  would  lead  in  the  case  of  living  tissue  to 
sclerosis   and   fibrous   scars.     If,  on   the    other   hand,   one  stretches  and 


Fig.  158. — Kollmann's  Foue-Bladed  Dilator:  Old  Pattern,  requiring  a  Rubber 

Sheath. 

widens  gently,  one  can  elongate  the  tissue  or  rubber  without  damaging 
it.  In  the  case  of  the  urethral  mucous  membrane,  the  conditions  and  the 
requirements  are  similar. 

As  in  the  case  of  dilatation  with  curved  sounds,  the  best  procedure 
appears  to  be  the  following : 

1.  The  patient  should  empty  his  bladder. 

2.  His  bladder  is  filled,  by  means  of  a  urethro- vesical  irrigation,  with 
boric  lotion  or  a  1 :  4,000  solution  of  oxycyanide  of  mercury. 

3.  The  urethra  is  dilated  by  means  of  KoUmann's  four-bladed 
dilator. 

4.  The  patient  passes  his  boric  or  mercurial  solution. 

At  each  visit  one  inserts  the  dilator,  and  turns  the  screw  slowly  and 
gently  until  the  patient  feels  that  his  urethra  is  being  dilated.  There  should 
be  no  pain.     One   leaves   the   instrument  in  the   urethra  for  five  to  ten 


Fig.  159. — Kollmann's  Four-Bladed  Dilator:  New  Pattern,  which  does  not 
REQUIRE  a  Rubber  Sheath. 


minutes.  More  than  two  apphcations  should  not  be  made  within  a  week, 
and  if  there  should  be  the  shghtest  pain  on  making  water  or  the  least  trace 
of  hemorrhage,  one  dilatation  is  enough,  and  one  should  not  increase  the 
stretching  by  more  than  one  number  of  the  scale,  or  two  at  the  outside. 
Occasionally,  even,  one  should  not  hesitate  to  remain  below  the  last  figure 
reached,  if  one  finds  the  urethral  mucous  membrane  very  tender  when  one 


336  GONOREHEA 

begins  the  dilatation.      In  no  case  should  one  go  beyond  two  or  three 
numbers  at  one  apphcation. 

With  these  instruments  a  most  satisfactory  dilatation  is  obtained,  and 
one  can  control  the  progress  made  by  passing  at  each  visit  an  exploratory 
oHve.     The  discharge  dries  up  and  the  filaments  disappear. 


Fig.  160. — Kollmann's  Four-Bladed  Dilator  in  Use. 

Irrigating  Dilators. — Various  authors  have  recommended  to  combine 
dilatation  and  irrigation,  and  have  invented  special  instruments  for  this 
purpose. 

De  Sard's  "  benique  laveur,"  for  instance,  consists  of  a  curved  metal 
sound  which  is  fitted  with  four  deep  grooves  instead  of  being  cyhndrical. 
The  distal  end  of  each  groove  presents  a  small  hole,  through  which  the 

1  De  Sard,  Ann.  Genito-Urin.,  1904,  p.  359. 


THE  TREATMENT  OF  CHRONIC  GONORRHEA 


337 


irrigating  fluid  leaves  the  hollow  of  the  instrument  and  reaches  the  urethra. 
This  sound  is  passed  in  the  ordinary  way;  one  then  adapts  the  special  joint 
and  runs  the  fluid  in  from  an  irrigator. 

Jeanbrau's  ^  irrigating  dilator  consists  of  a  sound  No.  45  G-  which  is 
quadrangular  in  its  straight  portion,  and  is  di%dded  into  four  branches  by 


Fig.  161. — De  Sard's  Benique  Lavetjr. 

four  deep  grooves.  Each  branch  is  perforated  by  a  number  of  small  holes, 
and  all  angles  are  rounded  off.  A  hollow  tube  carrying  four  holes  near 
its  end,  and  fitting  firmly,  is  passed  into  the  sound.  The  liquid  is  run  in 
through  it,  and,  as  it  can  be  moved  to  and  fro  within  the  sound,  the  whole 
urethra  can  be  irrigated. 


Fig.  162. — Jeanbrau's  Irrigating  Sound. 

Besides  these  simple  instruments  we  have  KoUmann's  irrigating  dilators.? 

In  order  to  be  able  to  appreciate  their  value,  one  must  have  seen  with 
the  urethroscope  the  mucous  plugs  which  occasionally  occlude  the  orificeg 
of  Littre's  glands  and  of  the  lacunse  of  Morgagni.  These  plugs  are  sHghtly 
adherent,  and  these  instruments  have  been  constructed  for  the  purpose 

1-  Jeanbrau,  "  Laveur  Uretral,"  Ass.  Frang.  d'UroL,  1908,  p.  167. 
2  Menahem  Hodara,  "Les  Noveaux  Dilatateurs-Laveurs  deKollmann,'MTOTO.  Genito- 
Urin.,  1898,  No.  10,  p.  1009. 

22 


338 


GONOERHEA 


of  washing  them  away  mechanically,  and  of  rendering  thus  the  glandular 
orifices  widely  gaping. 

They  carry  four  branches  similar  to  those  of  Kollmann's  other  dilators. 
They  are  grooved,  and  do  not  require  a  rubber  sheath. 

There  are  straight  and  curved  models.  In  each  case  there  is  a  double 
channel  for  the  circulation  of  water.  The  irrigating  fluid  enters  through  one 
of  the  blades,  and  passes  into  the  axis  of  the  instrument,  which  it  leaves 
through  one  of  the  four  httle  holes  at  its  end.     In  this  way  the  mucous 


Fig.  163. — Kollmaistn's  Shobt  Straight  Irrigating  Dilator. 

membrane  is  washed  from  behind  forwards,  and,  as  it  is  well  spread  out,  it 
is  properly  cleansed.  The  muco-purulent  masses  are  set  free  and  washed 
away  to  such  an  extent  that  the  gland  ducts  become  accessible  to  the  action 
of  the  drug  used  for  the  irrigation.  This  treatment  is  carried  out  every 
eight  or  ten  days  on  the  average.  If  it  does  not  set  up  any  irritation,  one 
can  resort  to  it  once  every  five  or  six  days. 

As  a  rule,  one  uses  a  boric  acid  solution  in  connection  with  this  instrument, 
and  allows  1  to  2  htres  to  flow  whilst  the  urethra  is  being  dilated.  In  some 
cases  a  weak  solution  of  silver  nitrate  (T:  8,000)  is  useful.     One  should 


Fig.  164. — Kollmann's  Long  Straight  Irrigating  Dilator. 

continue  the  irrigation  whilst  the  branches  of  the  instrument  are  being 
brought  together  and  during  its  withdrawal,  in  order  to  prevent  all  injury 
to  the  mucous  membrane. 

Generally  speaking,  permanganate,  especially  in  strong  solution,  should 
not  be  used  for  these  irrigations.  Its  use  is  often  followed  by  a  marked 
constriction  of  the  urethral  mucous  membrane.  The  dilator  may  then  be 
so  firmly  gripped  that  one  can  hardly  withdraw  it,  and  any  violence  is  sure 
to  be  followed  by  a  tearing  of  the  mucous  membrane. 

Another  point  of  importance  is  the  temperature  of  the  solution  employed. 


THE  TREATMENT  OF  CHRONIC  GONORRHEA  339 

Experience  has  shown  that  far-pushed  dilatations  with  the  four-bladed 
instrument  are  often  followed  by  a  characteristic  sensation  of  pain,  and  that 
irrigation  with  a  hot  solution  of  boric  acid  attenuates  or  subdues  this  pain 
almost  instantaneously.  This  analgesic  action  of  hot  water  may  be  taken 
advantage  of  for  dilatations  of  a  high  degree. 

Curved  Dilators. — These  instruments  are  intended  for  dilating  the  pos- 
terior urethra.  Some  act  chiefly  on  the  bulbous  portion,  others  dilate 
mainly  the  perineal  part,  and  others,  again,  hke  Frank's  instrument,  widen 
especially  the  prostatic  urethra.  The  more  recent  models  no  longer  require 
a  rubber  sheath,  their  dilating  blades  being  grooved  hke  those  of  the  new 
instruments  for  the  anterioir  urethra.     There  are  instruments  on  the  market 


Fig.  165.— Oberlander's  Dilator  for  the  Posterior  Urethra. 


Fig.  166. — Kollmann's  Curved  Dilator  to  be  used  with  a  Rubber  Sheath. 

which  will  pass  through  a  narrow  meatus,  and  there  are  some  very  powerful 
models  suitable  for  high  degrees  of  dilatation.  Lastly,  some  allow  one  to 
dilate  and  to  irrigate  simultaneously. 

Dilatation  of  the  Posterior  Urethra. — The  posterior  urethra  is  dilated,  to 
begin  with,  with  curved  metal  sounds.  When  the  urethroscopic  control 
shows  that  the  dilatation  has  been  inadequate  and  that  lesions  are  left, 
it  becomes  necessary  to  resort  to  special  instruments.  One  of  the  best 
instruments  for  this  purpose  is  Frank's  (of  Berlin)  three-bladed  irrigating 
dilator,  which  widens  outthe  prostatic  portion  and  irrigates  it  at  the  same  time. 

Technique. — After  the  patient  has  made  water  and  his  bladder  has  been 
filled  by  means  of  a  urethro-vesical  irrigation,  the  instrument  is  passed. 
The  patient  should  be  placed  in  the  semi- inclined  position;  he  should  neither 
be  sitting  nor  lying  down;  his  pelvis  should  rest  on  the  edge  of  the  couch, 
and  his  feet  should  be  supported  by  stirrups.  His  back  may  lean  against  a 
rest  placed  almost  horizontally. 


340 


GONORRHEA 


Once  the  dilator  has  been  passed,  one  turns  the  big  screw  until  there  is  a 
shght  sensation  of  discomfort.  One  now  connects  the  instrument  with  an 
irrigator  filled  with  hot  boric  lotion,  and  begins  the  irrigation.  The  washings 
are  collected  in  a  glass  as  they  come  out,  and  are  examined  carefully.  In 
nearly  every  case  one  will  find  them  to  be  turbid,  or  at  any  rate  not  to  be 
perfectly  clear,  and  they  gradually  become  clearer  as  the  irrigation  is  con- 
tinued.    One  can  then  continue  the  dilatation,  but  this  should  be  done  with 


Fig.  167. — Kollmann's  Curved  Dilator  requiring  No  Rubber  Sheath. 


Fig.  168. — Kollmann's  Curved  Irrigating  Dilator. 


Fig.  169. — Frank's  Dilator  for  the  Posterior  Urethra. 


great  caution,  in  order  to  avoid  any  hemorrhage  from  the  mucous  membrane. 
To  a  certain  extent  one  can  control  the  absence  of  bleeding  by  watching  the 
irrigating  fluid  as  it  comes  out. 

However,  this  is  not  always  rehable.  There  are  cases  in  which  there  is 
no  trace  of  blood  during  the  dilatation.  But  once  one  has  closed  the  instru- 
ment and  withdrawn  it,  either  drops  of  blood  show  themselves  immediately 
at  the  meatus,  or  the  boric  lotion  is  mixed  with  blood  as  it  is  passed. 

The  first  rule  which  should  be  observed  when  dilating  the  posterior 


THE  TREATMENT  OF  CHRONIC  GONORRHEA 


341 


urethra  with  this  instrument  is  to  proceed  gently  and  slowly.  One  should 
never  increase  the  dilatation  by  more  than  one  or  two  numbers  during  one 
application,  and  one  should  allow  long  intervals  between  the  various  visits 
if  there  is  any  bleeding  from  the  urethra.  In  the  latter  case,  one  should  not 
even  dilate  farther,  but  should  keep  to  the  last  number  reached  until  there 


Fig.  170. — Dilatation  op  the  Posterior  Urethra  with  Frank's  Instrument: 

Position  op  the  Patient. 


is  not  the  shghtest  trace  of  blood.  The  intervals  should  last  ten  to  fifteen 
days,  or  even  three  weeks. 

The  Precautions  which  should  be  taken  with  High  Dilatations. — In  the 

first  place,  these  far-pushed  dilatations  should  only  be  carried  out  slowly 
and  methodically.  Unless  these  two  conditions  be  fulfilled,  this  treatment 
cannot  do  any  good. 

It  is  advisable  to  wash  the  urethra  by  means  of  a  urethro- vesical  irri- 


342  GONOEEHEA 

gation,  and  to  leave  a  certain  quantity  of  boric  lotion  in  the  bladder  before 
beginning  the  dilatation.  The  patient  is  then  able,  after  the  dilator  has  been 
withdrawn,  to  pass  the  solution  and  to  free  his  urethral  mucosa  immediatelv 
from  the  glandular  exudates  which  have  been  squeezed  out  by  the  dilatation. 
This  procedure  is  better  than  a  second  irrigation,  which  would  distend  and 
stretch  once  more  the  mucous  membrane,  which  has  already  been  bruised 
sufficiently  by  the  dilator.  It  also  avoids  the  bleeding  which  might  follow 
in  the  other  case.  Another  advantage  is  the  possibihty  of  being  able  to 
collect  the  first  stream  of  the  boric  solution,  which  contains  any  pathological 
secretions  which  may  come  away.  The  latter  can  then  be  examined  macro- 
scopicaUy  and  microscopically. 

For  the  'pain  caused  by  these  dilatations,  which  is  sometimes  severe, 
the  use  of  a  local  anesthetic  is  advisable.  One  of  the  best  methods  con- 
sists in  injecting  8  to  10  c.c.  of  a  1  per  cent,  solution  of  stovain.  In  some 
cases  this  procedure  is  inadequate.  It  is  then  well  to  give  a  hot  irrigation 
through  the  irrigating  dilator.  In  nearly  every  instance  the  pain  will  then 
cease. 

One  of  the  best  means  of  avoiding  hemorrhage  from  the  urethra  consists 
in  resorting  to  urethroscopy  before  one  uses  the  dilator.  All  sorts  of  acci- 
dents can  be  avoided  in  this  way,  and  one  is  enabled  to  follow  step  by  step 
the  progress  achieved.  Moreover,  in  the  case  of  hemorrhage,  one  can  locate 
the  bleeding  spot,  the  site  of  the  tear,  and  convince  oneseK  of  the  necessity 
of  allowing  considerable  intervals  between  the  various  dilatations.  As  long 
as  the  tear  is  not  completely  cicatrized,  any  attempt  to  dilate  merely  separ- 
ates its  edges,  whilst  the  action  on  the  healthy  parts  of  the  mucous  mem- 
brane is  nil.  Carried  out  with  care  and  under  the  control  of  the  urethro- 
scope, dilatation  is  most  beneficial;  but  it  is  valueless,  and  may  even  become 
dangerous,  if  it  is  resorted  to  in  a  bhnd,  haphazard  fashion.  When  one 
examines  a  case  of  urethrorrhagia  subsequent  upon  dilatation,  one  invariably 
finds  the  same  lesion :  the  bleeding  always  comes  from  the  most  sclerosed  part, 
and  is  due  to  a  longitudinal  fissure  which  runs  in  the  direction  of  the  urethra. 
The  blood  wells  up  from  the  gap  between  the  two  Hps.  If  we  continue  to 
dilate,  we  separate  the  edges  of  the  wound  farther  and  make  matters  worse. 
The  urethral  walls  no  longer  undergo  dilatation  ;  all  stretching  ejects  exclu- 
sively the  tear.  In  many  cases  the  patients  themselves  become  aware  of  this 
fact.  When  we  increase  the  dilatation  by  one  degree,  the  patient  feels  a 
sHght  pain.  But  when  we  dilate  to  such  an  extent  that  we  rupture  the 
mucous  membrane,  the  edges  of  the  tear  are  separated  and  there  is  no  longer 
any  sensation  of  pain.  One  should  pay  attention  to  this  point,  as  it  is  diag- 
nostic of  injury.  The  conclusion  to  be  drawn  from  all  this  is  that  it  is 
necessary  to  allow  a  long  interval  every  time  a  far-pushed  dilatation  has 
given  rise  to  a  certain  amount  of  hemorrhage  from  the  urethra,  and  that 


THE  TREATMENT  OF  CHRONIC  GONORRHEA 


343 


one  must  not  go  beyond  the  last  number  reached.  In  many  cases  a  pause 
of  two  or  three  weeks  or  more  is  necessary,  and  occasionally  one  will  even  not 
attempt  to  reach  the  last  highest  number.  If  one  proceeds  in  this  fashion, 
one  gives  the  tear  a  chance  to  heal,  the  urethral  lumen  becomes  wider,  and 
subsequent  dilatations  stretch  the  whole  circumference  equally. 

Generally  speaking,  we  may  say  that  this  method  of  far-pushed  dilata- 
tion gives  excellent  results  in  chronic  anterior  urethritis.  This  condition  is 
unfortunately  very  common  and  extremely  rebelhous  to  treatment.  It  is 
characterized  by  small  nodules  which  can  be  felt  along  the  urethra,  and  a 
sUght  mucous  or  muco-purulent  oozing  from  the  passage,  and  heavy  fila- 
ments in  the  first  glass  of  urine.     Patience  is  required  for  its  treatment,  and 


Fig.  171. — The  Effect  of  Violent  Dilatatiok  on  a  Sclerosed  Urethral  Mtrcoirs 

Membrane. 

The  action  of  the  dilatation  concentrates  itself  on  the  tear  produced.  It  separates 
its  edges  farther,  and  has  no  effect  on  the  uninjured  parts  of  the  fibrous  tissue  in 
the  urethra. 


the  patients  should  be  informed  of  this  fact.  The  dilatations  should  be 
continued  slowly  and  methodically  until  the  highest  Hmit  is  reached.  The 
ultimate  success  and  the  obtainment  of  a  complete  cure  will  compensate  for 
these  prolonged  efforts. 

Adjuvant  Methods  to  Dilatation.  —  Whether  one  dilates  with  curved 
metal  sounds  or  with  a  dilator,  there  often  comes  a  moment  when  the  urethra 
will  no  longer  stretch.  After  a  certain  degree  of  dilatation  has  been  reached, 
all  further  attempts  give  rise  to  excessive  pain,  or  they  are  followed  by 
hemorrhage,  despite  the  long  intervals  which  one  may  allow  to  elapse  between 
the  various  treatments. 

It  then  becomes  desirable  to  interrupt  the  dilatations  for  a  time, 
and  to  resort  to  a  method  which  will  prepare  the  urethra  for  further 
widening. 


344  GONOEKHEA 

We  have  two  means  at  our  disposal  for  doing  this : 

1.  Complementary  urethrotomy. 

2.  Electrolysis. 

1.'  Complementary  Urethrotomy. — The  aim  of  complementary  ure- 
throtomy consisfcs  in  sectioning  the  fibrous  portions  in  the  urethral  mucous 
membrane  by  means  of  a  sharp  blade. 

Amongst  the  various  instruments  devised  for  this  purpose,  Kollmann's 
urethrotome  is  one  of  the  best. 

Like  Civiale's  urethrotome,  it  incises  the  strictures  from  behind  forwards 
by  means  of  a  knife.  Its  distal  end  carries  an  ohve,  between  the  halves  of 
which  the  blade  is  made  to  project  by  working  a  special  mechanism  on  the 


Fig.  172. — Kollmann's  Urethkotome. 


handle.  A  number  of  ohves  of  different  sizes  are  supphed,  and  one  selects 
the  largest  one  which  will  just  enter  the  stricture.  The  blade  should  only 
divide  the  stricture  after  the  latter  has  been  rendered  tense. 

This  instrument  enables  one  to  operate  with  a  minimum  risk,  and  to 
divide  accurately  and  exclusively  the  fibrous  constriction  without  injury 
to  the  healthy  neighbouring  parts.     The  cuts  made  are  practically  bloodless. 


Fig.  173. — Fessenden  Otis' s  Urethrotome. 


and  therefore  the  patient  can  follow  his  occupation  and  need  not  he  up. 
After  two  or  three  days  one  can  resume  the  dilatations,  and  when  again  no 
progress  is  made  the  urethrotomy  may  be  repeated  once  or  twice. 

Amongst  the  other  instruments  for  complementary  urethrotomy,  those 
which  have  been  designed  for  cutting  the  strictures  only  after  they  have 
been  fully  dilated  are  to  be  preferred.     Fessenden  Otis' s  instrument,  which 


THE  TREATMENT  OF  CHRONIC  GONORRHEA      345 

is  shown  in  Fig.  173,  answers,  but  it  makes  longer  and  deeper  incisions 
than  Kollmann's  urethrotome.^ 

2.  Electrolysis. — Electrolysis  is  an  extremely  interesting  and  powerful 
method  which  should  be  frequently  used  as  an  adjuvant  to  dilatation. 

We  are  only  speaking  here  of  circular  electrolysis  (Newman's  method), 
which  makes  use  of  weak  currents  acting  on  a  large  surface. 

It  allows  one  to  progress  rapidly  in  cases  in  which  the  strictures  are  so 
marked  that  simple  dilatation  is  difficult,  if  not  useless. 

It  can  be  applied  in  two  different  ways : 

(1)  With  ordinary  curved  sounds. 

(2)  With  the  electrolyser. 

(1)  With  Ordinary  Curved  Sounds. — In  the  case  of  tight  strictures  which 
render  the  dilatation  with  ordinary  curved  sounds  difficult  or  impossible, 
circular  electrolysis  gives  excellent  results,  as  Desnos  has  shown. 

Technique. — After  the  patient  has  made  water,  one  fills  his  badder  with 
boric  lotion  by  means  of  a  urethro- vesical  irrigation.  The  battery,  which 
should  be  fitted  with  a  milhamperemeter,  should  be  close  at  hand.  A  sheet 
of  lead  is  connected  with  the  positive  pole  and  placed  on  the  right  thigh  of 
the  patient,  where  it  is  kept  in  position  and  in  close  contact  by  the  right 
hand  of  the  patient.  The  negative  pole  is  attached  to  the  metal  sound  by 
means  of  a  pair  of  artery  forceps.  One  then  introduces  the  sound  in  the  usual 
way;  at  the  same  time  a  current  of  8  to  10  milhamperes  is  passed.  Normally, 
the  point  of  the  sound  is  stopped  when  it  reaches  the  narrowest  part  of  the 
stricture.  It  is  most  wonderful  to  witness  how  the  sound  passes,  after  a  few 
minutes,  with  the  greatest  ease,  as  if  one  had  given  an  injection  of  oil  at  the 
level  of  its  tip.  One  should  never  go  beyond  8  to  10  milhamperes,  and 
should  not  prolong  the  electrolysis  for  more  than  five  or  six  minutes.  One 
should  also  not  take  too  large  an  instrument  for  the  purpose  of  overcoming 
the  stricture  with  the  aid  of  electrolysis.  One  takes  one  size  larger  than 
the  biggest  sound  which  passed  unassisted.  With  this  technique  accidents 
are  practically  excluded. 

(2)  The  Use  of  the  Electrolyser. — A  good  number  of  cases  of  chronic  ure- 
thritis are  considerably  improved  by  the  dilatation  of  curved  metal  sounds 
up  to  No.  60  G,  but  they  are  not  cured. 

The  urethroscope  often  shows  in  these  cases  well-marked  zones  of  fibrous 
tissue,  for  the  cure  of  which  one  resorts  to  dilatation  by  means  of  Kollmann's 
four-bladed  instrument. 

After  a  few  apphcations  one  reaches  a  maximum  beyond  which  the  dila- 
tation will  not  advance,  even  if  one  uses  a  certain  amount  of  force.     The 

1  Another  excellent  instrument  is  Albarran's  urethrotome  in  its  modification  by 
Desnos  (A.  F.). 


346 


GONOREHEA 


instrument  is  fixed,  as  if  it  were  embedded  in  cement,  and  its  blades  cannot 
be  separated  any  farther. 

Electrolysis  is  then  most  useful,  and  can  be  carried  out  by 
one  of  the  three  following  methods: 

(a)  The  negative  pole  can  be  connected  directly  with  the 
four-bladed  dilator.  This  procedure  is  not  always  satisfactory. 
(6)  One  can  use  Newman's  metallic  ohves,  which  must  be 
connected  with  the  negative  pole.  However,  it  is  not  often 
that  one  can  find  a  meatus  which  will  admit  sizes  beyond  60  G, 
even  if  one  has  dilated  up  to  this  number  previously.  This 
method  is  therefore  restricted  to  very  few  cases. 

(c)  With  the  Electrolyser. — In  order  to  remedy  these  diffi- 
culties, I  have  devised  a  special  electrolyser  which  is  con- 
structed on  the  principle  of  Kollmann's  four-bladed  dilator.^ 

Technique. — After  the  bladder  has  been  filled  in  the  usual 
way,  the  instrument  is  introduced  closed  beyond  the  stricture  or 
strictures.  One  then  opens  out  its  blades  by  turning  the  large 
or  terminal  screw.  The  strictures  are  thus  approached  from 
behind,  and  one  has  only  to  keep  the  instrument  in  contact 
with  them  for  a  few  minutes  to  find  that  it  passes  the  most 
constricted  places  without  any  great  difficulty.  It  is  essential 
that  these  manipulations  be  carried  out  gently  and  very  gradu- 
ally. The  electrolytic  dilatation  should  be  increased  after  long 
intervals  of  eight  days,  or,  better,  of  two  weeks,  and  a  current 
stronger  than  5  to  10  milhamperes  should  not  be  used. 

It  is  most  interesting  to  find  that,  under  the  influence  of 
these  applications,  ordinary  dilatation  practised  in  the  inter- 
vals gives  results  which  are  beyond  all  expectation.  By  using 
simple  and  electrolytic  dilatation  alternately,  one  is  enabled, 
with  patience  and  time,  to  remove  all  indurated  patches  in 
the  urethra — even  the  most  inveterate  ones. 


6.  Urethroscopic  Treatment. 

Urethroscopic  treatment  comprises  all  those  direct 
applications  to  the  urethral  mucous  membrane  which 
are  carried  out  under  the  control  of  the  urethroscope. 

The  advantages  of  this  form  of  therapy  are  easily 

understood  owing  to  their  precision.     It  allows  one  to 

apply  the  topic  exactly  to  the  diseased  spot  without  interfering  with  the 

healthy  portions  in  the  neighbourhood.     This  method  is  apt  to  render  one 


Fig.  174. — Luys's 
Electrolyser. 


^  This  instrument  was  shown  in  1909  at  the  Societe  des  Chirurgieris  de  Paris. 


THE  TREATMENT  OF  CHRONIC  GONORRHEA     347 

enthusiastic,  and  one  experiences  a  great  pleasure  when  one  finds  that  one 
has  produced  a  radical  and  complete  cure  after  having  burnt  and  destroyed 
one  certain  circumscribed  lesion  in  the  urethra. 

However,  one  should  not  exaggerate  the  advantages  of  this  method 
which  should  be  reserved  for  certain  special  cases.  As  we  have  already 
mentioned,  this  form  of  treatment  should  be  restricted  to  those  cases  of 
chronic  urethritis  in  which  dilatation  has  exerted  its  entire  effect.  Its  use 
should  therefore  always  follow  upon  dilatation;  it  is  not  a  primary  treatment. 

The  chief  endo-urethral  interventions  in  chronic  urethritis  are — 

1.  Local  cauterization  of  the  diseased  areas  with  caustics. 

2.  Electrolysis  of  inflamed  lacunae  and  follicles. 

3.  Intra-urethral  cauterization  with  the  galvano-cautery. 

4.  Surgical  incisions  of  the  urethral  mucous  membrane. 

1.  The  Local  Application  of  Caustics. — Local  applications  of  caustics, 
carried  out  under  the  control  of  the  eye,  which  produce  a  certain  and  power- 
ful action  on  the  diseased  patches  without  injuring  the  healthy  tissues,  are 
incontestably  superior  to  all  other  methods  which  have  the  same  purpose. 

For  urethro-vesical  irrigations  and  injections  with  a  syringe  only  weak 
solutions  can  be  used.  Moreover,  their  action  is  a  "  blind"  one,  as  they 
affect  the  healthy  parts  as  well  as  the  diseased  ones.  If  they  be  too  strong, 
they  damage  the  healthy  tissues  unnecessarily,  and  if  they  be  too  weak,  they 
do  not  modify  the  diseased  surfaces. 

The  instillations  have  been  invented  largely  for  the  purpose  of  over- 
coming this  defect.  There  is  no  doubt  that  this  latter  method,  which 
aims  at  depositing  a  few  drops  of  a  concentrated  caustic  solution  on  the 
diseased  focus,  often  gives  good  results;  but  it  has  serious  drawbacks  {vide 
Instillations). 

The  urethroscopic  method  is  preferable  for  various  reasons:  Firstly, 
the  diseased  points  are  treated  directly  under  the  guidance  of  the  eye; 
secondly,  they  alone  are  modified  and  the  surrounding  healthy  parts  are  not 
tampered  with;  and,  thirdly,  they  allow  a  most  powerful  eflect  if  one  uses  a 
highly  concentrated  caustic. 

Technique. — After  the  urethroscopic  tube  has  been  passed  according  to 
the  rules  laid  down  in  Chapter  VIII.,  and  after  one  has  made  out  accurately 
the  site  of  the  lesion  which  one  wishes  to  cauterize,  one  tries  to  get  the  diseased 
area  well  within  the  field  of  the  tube. 

One  should  never  fail  to  pass  the  urethroscope  as  far  as  possible  into  the 
urethra,  and  to  cauterize  the  deep  lesions  first.  As  one  withdraws  the  tube, 
one  deals  with  the  more  anterior  ones.  It  would  be  a  great  mistake  to  act  in 
the  inverse  fashion,  and  to  pass  the  tube  over  patches  which  one  has  already 
cauterized,  because  it  would  lead  to  unnecessary  bleeding. 


348  GONOREHBA 

Moreover,  before  applying  a  caustic  to  any  place,  the  latter  should  be 
properly  cleaned  with  swabs,  and  any  blood  or  secretion  covering  it  should 
be  wiped  away.  One  can  then  see  what  one  is  doing,  and  treat  the  lesions 
thoroughly  without  interfering  with  the  surrounding  healthy  parts. 

A  light  touch  is  required  and  a  complete  control  over  the  instruments. 
In  certain  cases  only  a  gentle  dab  with  the  caustic  is  required;  on  other  occa- 
sions one  has  to  apply  it  firmly. 

After  having  inspected  and  treated  all  the  diseased  areas,  one  withdraws 
the  urethroscopic  tube,  and  leaves  the  urethra  alone  for  at  least  a  week. 


Fig.  175. — Caustic-Holdek  for  Intra-Ubethkal  Cauterization. 

At  the  most,  a  few  irrigations  with  hot  boric  lotions  may  be  given  in  the 
interval. 

Substances  used. — The  chief  and  most  frequently  employed  drug  is  silver 
nitrate.  Its  action  is  well  known;  it  is  potent  and  efficient.  I  have  indi- 
cated a  little  mould  for  making  small  sticks  which  can  be  mounted  on 
special  holders  {vide  Fig.  175). 

Silver  nitrate  is  not  always  used  in  the  solid  form;  a  strong  solution  is 
often  of  great  service.     Thus,  a  10  per  cent,  solution  apphed  correctly  to 


Fig.  176. — Kollmann's  Special  Cannula  for  injecting  Drugs  into  the 
Glandular  Ducts  op  the  Urethral  Mucous  Membrane. 

the  diseased  areas  often  gives  excellent  results;  it  does  not  diffuse,  and 
causes  no  pain. 

Pure  tincture  of  iodine  is  another  excellent  drug.  Its  use  is  chiefly 
indicated  when  the  urethral  mucous  membrane  is  covered  with  a  desqua- 
mating epithehum  of  a  greyish- white  colour  which  reminds  one  of  a  layer  of 
dust,  similar  to  the  aspect  in  urethral  leucoplasia. 

Crystals  of  sulphate  of  copper  can  also  be  used  in  alternation  with  silver 
nitrate,  and  good  results  can  be  obtained  from  their  use. 

Resorcin  in  a  concentrated  solution  containing  glycerine  is  of  value  in 


THE  TREATMENT  OF  CHRONIC  GONORRHEA     349 

certain  cases.    Janet  advocated  its  use  at  the  Urological  Congress  in  1904  for 
the  destruction  of  certain  vegetations  and  polypi.^ 

Occasionally  it  is  necessary  to  introduce  these  topics  into  little  cavities — 
for  instance,  into  the  lacunae  of  Morgagni  or  some  other  diverticulum  of  the 
mucous  membrane.  Professor  KoUmann  has  devised  a  small  syringe  on 
which  a  long  cannula  is  mounted  for  these  injections. 

The  cases  in  which  direct  applications  of  silver  nitrate  are  most  successful, 
are  those  in  which  the  urethroscopic  examination  has  revealed  the  presence 
of  characteristic  soft  infiltrative  lesions,  and  those  which  show  the  granula- 
tions which  commonly  mark  the  beginning  of  a  hard  infiltration. 

Excellent  results  are  obtained  when  the  mucous  membrane  forms  bulging 
or  oozing  masses  which  protrude  into  the  lumen  of  the  urethroscope  and 
imitate  hemorrhoids  {vide  Coloured  Plate  II.,  Fig.  1).  They  disappear  very 
quickly  under  a  thorough  application  of  silver  nitrate. 

One  can  also  be  certain  that  there  will  be  no  recurrence  if  one  cauterizes 
the  implantation  basis  of  httle  polypi  with  silver  nitrate  or  with  the  galvanic 
cautery  after  having  avulsed  them. 

Contra- Indications. — The  contra-indications  of  this  method  are  those 
which  apply  to  urethroscopy  {vide  Chapter  VIII.). 

This  method  is  only  apphcable  when  there  is  no  acute  or  recent  inflam- 
mation and  after  previous  urethroscopic  examinations. 

As  to  the  question  if  the  use  of  such  strong  active  remedies  could  not 
be  followed  by  serious  injuries  to  the  urethral  mucous  membrane,  we  are 
in  the  position  to  say  that  these  fears  are  not  justified.  Many  patients 
and  medical  men  beheve  that  the  application  of  pure  silver  nitrate  may  lead 
to  the  subsequent  formation  of  strictures.  Such  calamities  are  only  possible 
if  the  cauterization  has  been  done  in  a  brutal  and  careless  manner,  and  if 
one  has  omitted  the  necessary  intervals.  A  useful  precaution  is  the  fol- 
lowing: One  should  never  cauterize  the  whole  circumference  at  a  given 
spot  with  silver  nitrate.  One  should  dab  the  caustic  on  in  places,  leaving 
parts  untouched  between  the  treated  ones. 

If  one  follows  accurately  the  technique  which  we  have  outhned,  no 
untoward  results  or  accidents  can  arise.  On  the  contrary,  one  will  be 
agreeably  surprised  in  many  cases  at  the  astonishing  rapidity  with  which 
definite  curative  effects  are  obtained  without  giving  the  patient  any  suffering. 

This  is  well  shown  by  the  following  remarkable  case  which  I  have  treated: 

Blood-stained  Ejaculations  treated  by  Injections  of  Silver  Nitrate  into 

THE  Prostatic  Utriculus. 

A  young  man  of  twenty-four  acquired  gonorrhea  in  1902,  in  the  course  of  which 
a  right  epididy  mo -orchitis  developed.  Since  then  he  suffered  from  a  slight  discharge, 
which  was  most  marked  in  the  morning.     In  May,  1904,  when  I  saw  htm,  the  micro- 

1  Janet,  C.  R.  deVAss.  Frang.  d'Urologie,  1904,  p.  535. 


350  GONOEEHBA 

scopic  examination  of  his  discharge  revealed  nothing  except  leucocytes  and  cells. 
The  urine  was  uniformly  turbid  in  a  marked  degree  after  it  had  been  passed  into  four 
glasses.  The  right  lobe  of  the  prostate  was  definitely  tender  and  painful.  An  olivary 
bougie  No.  20  detected  the  presence  of  a  constriction  in  the  perineal  portion  of  the 
urethra. 

The  patient  was  thereupon  treated  with  prostatic  massage  and  the  passing  of  curved 
metal  sounds  until  No.  54  G  was  reached. 

This  therapy  brought  about  a  great  improvement;  the  discharge  ceased  and  the 
urine  became  clear  and  free  from  filaments. 

On  May  24, 1904,  urethroscopy  was  resorted  to.  The  condition  of  the  urethra  was 
found  to  be  satisfactory,  but  on  the  verumontanum  a  little  orifice  was  found  at  the  right 
part  of  the  utriculus,  from  which  some  whitish  matter  oozed. 

I  did  not  pay  much  attention  to  this  finding  at  the  time,  and  as  the  con- 
dition of  the  urine  was  perfect,  and  as  there  was  no  discharge,  I  interrupted  the 
treatment. 

In  December,  1904 — i.e.,  seven  months  later— the  patient  returned  with  a  new 
complaint.  He  was  still  free  from  discharge,  and  his  urine  was  perfectly  clear;  but 
his  ejaculations  had  been  tinged  with  blood  during  the  last  six  or  seven  weeks.  This 
definite  symptom  induced  me  to  urethroscope  him  again,  and  I  found  the  verumon- 
tanum to  be  definitely  enlarged  and  to  be  deviated  to  the  left  side.  On  its  right  lateral 
aspect  I  could  see  the  utriculus,  and  found  it  to  be  inflamed  and  gaping.  I  cauterized 
it  with  a  mounted  stick  of  silver  nitrate  and  examined  'per  rectum.  The  prostate  was 
normal,  but  the  right  seminal  vesicle  was  tender,  although  no  enlargement  or  indura- 
tion could  be  felt. 

On  January  30,  1905,  a  urethroscopic  tube  No.  26  was  passed.  The  verumon- 
tanum was  completely  examined,  and  a  few  drops  of  a  5  per  cent,  solution  of  silver 
nitrate  were  injected  into  the  utriculus  through  a  long  platinum  cannula.  It  was  easy 
to  see  that  the  injection  had  reached  the  spot,  as  the  verumontanum,  which  so  far  had 
been  flat,  became  turgid. 

On  February  7  the  patient  stated  that  this  injection  had  been  followed  by  a  slight 
pain  in  the  testicle,  but  that  his  ejaculations  were  less  red.  A  similar  injection  was 
therefore  given. 

On  February  13  the  patient  agam  stated  to  have  noticed  a  further  improvement, 
and  thus  a  third  injection  was  given. 

On  February  22  he  returned.  There  was  no  longer  any  blood  mixed  with  his 
sperma,  and  his  ejaculations  had  become  normal. 

2.  The  Urethroscopic  Treatment  of  Inflamed  Lacunae  and  Follicles. — One 

has  only  to  inspect  the  urethral  mucous  membrane  {vide  Fig.  15  and  Coloured 
Plate  III.)  in  order  to  realize  that  the  lacunae  of  Morgagni  and  the  glands 
of  Littre  are  eminently  favourable  recesses  in  which  the  gonococci  and  other 
organisms  can  develop  and  thrive  almost  indefinitely. 

These  urethral  diverticula  require  to  be  treated  by  the  ordinary  measures 
to  begin  with — i.e.,  by  irrigations,  and  especially  by  methodical  dilatation. 
But  there  are  cases — and  they  are  by  no  means  rare — in  which  the  urethro- 
scope reveals  the  presence  of  markedly  inflamed  lacunse  and  glands  even 
after  far-pushed  dilatation.  These  lesions  are  characterized  by  red, 
everted  edges,  and  the  gland  cavity  often  gives  issue  to  a  secretion 
which  can  be  seen  to  ooze  from  it.  This  condition  calls  for  a  direct 
local  therapy,  and  methods  of  this  kind  have  become  a  recognized  form 


THE  TREATMENT  OF  CHRONIC  GONORRHEA      351 

of  treatment  through  the  important  writings  of  Oberlander,  Kollmann, 
and  of  Janet. ^ 

Indication. — This  method  is  really  only  indicated  in  cases  in  which  far- 
pushed  dilatations  have  reached  the  hmit  of  their  action.  It  gives  good 
results  only  under  that  condition. 

The  treatment  of  choice  is  one  of  the  following:  (1)  Direct  electrolysis 
with  KoUmann's  electrolytic  needle,  or  (2)  cauterization  with  the  galvanic 
cautery. 

1.  The  Technique  of  Glandular  Electrolysis. — One  generally  uses  KoU- 
mann's electrolytic  needle  for  this  operation.  One  connects  it  with  the 
negative  pole  of  a  suitable  battery,  and  places  a  pad,  which  is  composed  of  a 
sheet  of  metal  surrounded  by  leather  saturated  with  saUne,  on  the  thigh  of 
the  patient.     This  is  the  positive  electrode. 

After  the  urethroscope  has  been  introduced  in  the  usual  way,  one  locates 
carefully  the  inflamed  lacunar  orifices,  and  passes  into  each  of  them  the  point 


Fig.  177. — Kollmann' s  Electrolytic  Needle. 

of  the  needle  as  far  as  possible,  using  a  current  of  4  to  6  milKamperes  at  the 
outside.  When  the  point  of  the  electrolytic  needle  is  in  contact  with  a 
diseased  point  of  the  mucous  membrane,  a  characteristic  mucous  froth  is 
formed  within  a  few  seconds. 

The  apphcation  lasts  in  most  cases  three  to  four  minutes,  and  is  not  dis- 
agreeable ;  it  never  gives  rise  to  any  marked  pain. 

This  electrolysis  under  the  control  of  the  urethroscope  should  not  be 
reserved  exclusively  for  the  treatment  of  inflamed  lacunse  and  folHcles;  it 
is  also  useful  as  a  treatment  of  other  pathological  conditions  met  with  in  the 
urethra,  such  as  angiomata. 

A  remarkable  case  of  this  kind  is  the  following,  which  demonstrates  the 
diagnostic  and  therapeutic  value  of  the  urethroscope.  We  owe  it  to  Pro- 
fessor Forgue  and  to  Dr.  Jeanbrau,  both  of  Montpelher. 

1  Janet,  C.  R.  de  I'Ass.  Frang.  d'  Urologie,  1903,  p.  419. 


352  GONORRHEA 

Sevebe  Repeated  Hemorrhage  from  the  Urethra  in  a  Boy  of  Fourteen,  catjsed 
BY  an  Angioma  which  was  diagnosed  by  Means  oe  Luys's  Urethroscope  ; 
Electrolytic  Treatment  under  the  Control  of  the  Urethroscope  ;  Cure. 

This  case,  which  was  brought  before  the  Association  rran9aise  d.'Urologie  in  1906 
by  Forgue  and  Jeanbrau,  refers  to  a  boy  of  fourteen  who  developed  in  November,  1905, 
spontaneous,  profuse  hemorrhages  from  his  urethra.  The  usual  hemostatic  measures 
proved  useless,  and  the  patient  continued  to  bleed  day  and  night  drop  by  drop.  The 
lad  thus  became  very  feeble,  and  Professor  Forgue  was  consulted,  who  suggested  the 
possibility  of  an  angioma  being  present  in  the  urethra.  The  meatus  was  slit  open  by 
means  of  the  electric  cautery  in  order  to  permit  the  passage  of  a  urethroscopic  tube 
No.  48  G,  and  Forgue  and  Jeanbrau  urethroscoped  the  patient  with  Luys's  instrument. 
As  the  tube  which  had  been  inserted  into  the  neck  of  the  bladder  was  gradually  with- 
drawn, they  found  the  urethra  to  be  normal  as  far  as  the  middle  of  the  penis.     Here, 


Fig.  178. — Urethroscopic  View  of  an  Angioma  of  the  Urethra  where  it 
occupies  only  a  Part  of  the  Circumference  of  the  Passage. 

in  the  anterior  third  of  the  spongy  urethra,  a  bluish  lumpy  swelling  was  discovered, 
which  presented  the  greatest  analogy  with  the  angiomata  whici  are  found  in  connection 
with  thin  mucous  surfaces,  such  as  the  floor  of  the  mouth.  In  places  this  swelling 
occupied  the  entire  circumference  of  the  urethra  and  obstructed  the  lumen;  in  others 
only  a  part  of  the  mucosa  was  involved.  The  figure  above  shows  a  part  of  the  tumour 
where  it  only  occupies  a  third  of  the  circumference.  Several  little  orifices  resembling 
pin-pricks  were  spread  over  its  surface,  and  from  them  blood  was  seen  to  ooze.  The 
source  of  the  hemorrhage  which  had  weakened  the  child  for  more  than  a  month  was 
thus  found. 

The  provisional  diagnosis  of  "angioma  of  the  urethral  mucous  membrane"  was 
thus  confirmed.  After  having  considered  the  difficulty  and  the  drawbacks  of  attempt- 
ing to  resect  3  centimetres  of  the  urethra — this  was  roughly  the  length  of  the  tumour — 
Forgue  and  Jeanbrau  decided  to  try  interstitial  electrolysis  under  the  control  of  the 
urethroscope.     They  operated  in  the  following  way:  After  having  passed  Luys's  tube 


THE  TREATMENT  OF  CHRONIC  GONORRHEA     353 

No.  48  G,  of  4  centimetres  length,  they  plunged  a  platinum  needle,  which  had  been 
carefully  isolated  and  been  connected  with  the  positive  pole,  into  the  substance  of  the 
angioma.  The  negative  pole  was  attached  to  a  sheet  of  tm,  surrounded  by  moistened 
cotton-wool,  which  was  placed  on  the  thigh  of  the  patient.  A  current  of  5  to  10  milli 
amperes  was  passed,  and  a  little  eschar  could  be  seen  to  form  at  the  level  of  the  needle. 
Fourteen  applications,  spread  over  a  period  of  three  months,  were  made,  and  led  to  the 
complete  disappearance  of  the  angioma.  The  hemorrhage  of  the  urethra  ceased  com- 
pletely after  the  eighth  electrolytic  intervention. 

Several  months  later  the  patient  was  again  urethroscoped,  and  one  was  able  to 
ascertain  that  a  cure  had  been  effected.  The  urethra  was  supple;  there  was  no  indura- 
tion or  rigidity.  The  site  of  the  angioma  was  of  a  pinkish-white  colour  traversed  by 
bands  of  whitish  cicatricial  tissue,  as  shown  in  Fig.  179.  The  mucous  membrane  had, 
however,  retained  its  elasticity.     It  gave  way  when  one  pushed  the  tube  onwards. 


Fig.  179. — ^Aspect  of  the  Urethra  after  it  had  been  cured  by  Means  of 
Interstitial  Electrolysis. 

and  came  together  on  its  withdrawal  with  equal  ease  in  the  healthy  and  in  the  treated 
parts.  The  cicatrices  around  the  positive  pole  are  soft  and  do  not  retract;  there  is 
no  reason  to  fear  the  development  of  a  stricture. 

MM.  Forgue  and  Jeanbrau  have  been  unable  to  find  a  similar  case  in  the  literature. 
They  remark  that  they  would  have  been  unable  to  diagnose  and  to  treat  this  angioma 
without  the  urethroscope.  In  the  ordinary  way  they  would  have  been  compelled  to 
open  the  urethra  and  to  resect  a  part  of  it.  Given  the  age  of  the  patient — -fourteen 
years — a  deformity  (incurvation)  of  the  penis  or  a  tight  stricture  would  have  probably 
resulted.  Thanks  to  the  urethroscope,  this  angioma  could  be  treated  with  the  same 
absence  of  risk  and  with  the  same  accuracy  as  if  it  had  been  on  the  skin. 

2.  The  Technique  of  the  Cauterization  Treatment  of  Inflamed  Lacunw. — 
As  the  use  of  the  galvano-cautery  in  the  treatment  of  urethral  affections 
will  be  described  at  length  in  a  special  paragraph,  we  will  here  only  point 

23 


354  GONOREHEA 

out  those  facts  which  have  a  direct  bearing  on  the  destruction  of  the  in- 
flamed lacunae  and  glands  by  means  of  the  electric  cautery. 

It  is  best  to  use  fine  cautery  points  made  of  platinum.  The  urethro- 
scopic  tube  is  firmly  held  in  position  with  the  left  hand,  and  its  end  within 
the  urethra  should  be  in  close  proximity  to  the  lacunae  which  one  desires 
to  burn.  One  brings  the  latter  into  the  lumen  of  the  tube,  and  maintains 
them  in  position  with  one  or  two  fingers  of  the  left  hand.  The  right  hand 
seizes  the  cautery  and  passes  it  into  the  tube.  One  apphes  the  point  whilst 
it  is  cold  to  the  lacuna,  and  pushes  it  as  far  as  possible  into  its  hollow.  One 
then  switches  on  the  current,  and  subsequently  withdraws  the  cautery. 

This  httle  operation  is  dehcate,  and  requires  a  certain  amount  of  skill. 
If  one  has  a  heavy  hand,  the  cautery  may  become  fixed  in  the  mucous 
membrane,  and  then  it  becomes  necessary  to  pass  a  stronger  current  to  free 
it  again.     In  this  way  one  produces  an  unnecessary  amount  of  damage. 

When  properly  apphed,  this  treatment  does  not  give  rise  to  any  acci- 
dents. There  is  never  the  slightest  trace  of  hemorrhage;  at  the  most,  a 
little  serous  discharge  may  be  noted  for  one  or  two  days.  As  a  rule,  this 
secretion  has  the  colour  of  barley-sugar,  and  disappears  after  seven  to  eight 
days. 

The  difficult  point  in  this  treatment  is  to  reach  all  the  inflamed  glands 
and  lacunae.  Very  often  the  diseased  glands  are  found  in  groups,  and  some 
of  them  escape  at  the  first  apphcation,  as  necessarily  the  largest  ones  attract 
one's  attention  most.  It  is  therefore  advisable  to  devote  several  visits  to  this 
treatment,  allowing  an  interval  of  ten  to  twelve  days  to  elapse  between  them. 

Another  inconvenience  is  the  production  of  smoke,  which  is  inevitable 
when  one  burns  tissues  with  the  cautery. 

By  means  of  two  precautions  this  smoke  nuisance  can  be  obviated. 

As  soon  as  one  has  finished  burning,  one  should  withdraw  the  cautery 
rapidly,  and  complete  the  destruction  of  the  material  which  adheres  to  it 
by  burning  it  outside  the  urethra.  Secondly,  one  should  swab  immediately 
with  a  few  dry  swabs.  In  this  way  a  draught  is  made  which  disperses  the 
fumes. 

Both  electrolysis  and  cauterization  with  the  galvanic  cautery  give 
excellent  results,  which  can  be  controlled  by  inspecting  the  mucous  mem- 
brane after  two  to  four  weeks  with  the  urethroscope.  When  all  the  inflam- 
mation set  up  by  the  treatment  has  subsided,  one  can  see  that  the  lacunae 
and  glands  which  have  been  destroyed  have  completely  changed:  instead 
of  red  and  inflamed  orifices  one  sees  inactive  httle  white  spots,  not  unhke 
extinct  volcanoes. 

3.  The  Treatment  of  Chronic  Urethritis  by  Means  of  the  Galvanic 
Cautery. — The  destruction  of  all  the  foci,  which  keep  up  a  urethral  discharge 
indefinitely,  by  burning  them  is  a  most  fascinating  method  which  should 


THE  TREATMENT  OF  CHRONIC  GONORRHEA  355 

be  received  with  unanimous  approval,  as  it  guarantees,  by  its  definition 
alone,  a  radical  cure. 

The  advantages  of  this  treatment  are  considerable.  It  substitutes  for 
a  localized  chronic  inflammation,  by  destroying  it,  a  white  scar  on  which  all 
recurrence  is  impossible. 

It  thus  produces  a  complete,  absolute,  certain,  and  definite  cure  of  the 
chronic  urethritis. 

There  are,  however,  a  few  weak  points  in  connection  with  this  method. 
Unless  one  is  well  acquainted  with  urethroscopic  work,  and  has  had  suffi- 
cient experience,  one  does  not  obtain  good  results.  Moreover,  skill  and  a 
Light  touch  are  required,  otherwise  one  might  produce  damage  and  accidents 
which  are  worse  than  the  evil  which  one  attempted  to  combat. 

Indications. — Endo-urethral  cauterization  with  the  galvanic  cautery  is 
chiefly  indicated  for  all  papillomatous  proHferations  which  develop  on  the 
urethral  mucous  membrane. 

For  lesions  of  this  type  destruction  by  burning  them  is  the  treatment  of 
choice.  It  is  infinitely  preferable  to  the  other  measures  which  have  been 
proposed,  such  as  avulsion  and  excision.  It  is  the  only  one  from  which  a 
permanent  and  lasting  cure  can  be  expected.  It  allows  one  to  approach 
directly  the  basis  of  the  polypus  or  of  the  papilloma,  and  to  destroy  it  com- 
pletely under  the  control  of  one's  eye. 

We  need  not  here  dwell  upon  the  frequency  with  which  papillomata  develop 
within  the  urethra,  especially  in  the  region  of  the  verumontanum.  Without 
the  aid  of  the  urethroscope  they  can  neither  be  diagnosed  nor  treated. 

But  before  applying  these  cauterizations  one  has  to  make  certain  that 
one  is  really  deahng  with  papillomata,  and  not  with  swellings  of  the  mucous 
membrane  resulting  from  soft  infiltration.  Cauterization  is  just  as  harmful 
in  the  latter  case — in  which  they  are  often  followed  by  disagreeable  hemor- 
rhage— as  they  are  beneficial  in  the  treatment  of  papillomata. 

Apart  from  these  tumours,  endo-urethral  cauterization  is  of  the  utmost 
value  for  destroying  inflamed  folHcles  and  lacunas.  They  rank  with  the 
electrolytic  treatment,  and  are  an  alternative  measure. 

When  Professors  Oberlander  and  KoUmann  advocated  the  electrolytic 
treatment  of  the  inflamed  lacunae  of  Morgagni  and  Littre's  glands,  they 
achieved  an  enormous  progress  in  the  therapy  of  chronic  urethritis,  and 
there  is  no  doubt  that  this  treatment  will  always  be  found  useful  when  the 
chronic  lesions  cover  a  small  area.  It  may  also  be  claimed  that  it  is  less 
apt  to  do  harm  and  less  difficult  to  apply,  and  that  it  can  be  repeated  very 
frequently.  The  use  of  the  galvanic  cautery,  on  the  other  hand,  is  simpler 
and  of  a  more  certain  and  rapid  action. 

Contra-Indications. — The  chief  contra-indications  to  endo-urethral 
cauterizations  are  those  which  apply  to  urethroscopy  in  general.     It  i.,  out 


356 


GONOEEHEA 


of  the  question  when  the  urethra  is  in  a  state  of  acute  inflammation,  and  it 
should  only  be  used  after  gradual  and  methodical  dilatation  of  a  high  degree 
has  rendered  the  mucous  membrane  smooth  and  has  soothed  the  inflamma- 
tory areas. 

It  is  therefore  advisable  in  most  cases  to  carry  out  a  far-pushed  dilatation 


Fig.  180. — Long  Cattteby  Burner  with  a  Fine  Point  for  the  Posterior  Urethra. 

treatment  before  one  resorts  to  the  use  of  the  cautery.  Without  this  pre- 
caution, considerable  hemorrhage  may  supervene,  which  prevents  one  from 
seeing  distinctly  and  from  cauterizing  the  right  place. 

Technique — Instrumental   Outfit. — In    the    first   place,    a   urethroscope, 
such  as  Luys's,  is  required  {vide  Chapter  VIII.). 


^^saiBMBt^^iglJi 


Fig.  181.— Cautery  Blade  for  the  Anterior  Urethra. 

One  should  have  quite  an  arsenal  of  cautery  blades  and  points  at  one's 
disposal,  as  different  conditions  require  different  instruments.  The  long 
and  very  pointed  burners  are  cEiefly  used  for  deahng  with  Morgagni's 
lacunae,  Littre's  glands,  and  other  recesses  in  the  urethral  mucous  mem- 


FiG.  182. — Burner  with  a  Fine  Point  for  the  Anterior  Urethra. 

brane.     The  broad  and  thick  blades  are  destined  for  the  destruction  of 
polypi  which  spring  from  the  walls  of  the  passage. 

Lastly,  there  are  patterns  of  the  shape  of  a  spiral  which  are  mainly 
used  for  papillomata  of  a  certain  size.     They  are  especially  intended  for 


F= 


Fig.  183. —  Special  Spiral-shaped  Burner  for  Large  Papillomatous  Surfaces. 

the  destruction  of  the  large  papillomata  which  one  finds  in  the  posterior 
urethra  and  at  the  level  of  the  bulb. 

Operative  Technique. — It  is  well  to  have  an  assistant,  although  this  is 
not  absolutely  necessary.     His  chief  occupation  consists  in  supporting  the. 


THE  TREATMENT  OF  CHRONIC  GONORRHEA 


357 


wires  of  the  cautery  in  order  to  relieve  the  hand  of  the  operator  and  insure 
the  hghtness  of  his  touch. 

After  the  urethroscope  has  been  introduced  and  the  hght  has  been 
switched  on,  one  dries  the  urethral  mucous  membrane  very  thoroughly. 
It  is  absolutely  necessary  that  one  should  be  able  to  see  very  clearly  and  to 
find  the  diseased  areas  with  accuracy.  If  there  should  be  any  hemorrhage, 
which  interferes  with  vision,  one  swabs  until  it  has  ceased,  or  one  apphes  a 
few  drops  of  adrenahn  to  the  bleeding  spot.  When  all  hemorrhage  has  been 
subdued,  one  places  the  lamp  diametrically  opposite  the  focus  which  one 
wishes  to  destroy.  If  the  latter  be  on  the  upper  wall,  the  lamp  and  handle 
of  the  instrument  should  be  below,  and  vice  versa.     In  this  way  one's  manipu- 


FiG.  184. — Destruction  of  a  Polypus  on  the  Vekumontanum  by  Means  of 
Endo-Ubethral  Cauterization  with  the  Galvanic  Cautery. 

lations  are  never  interfered  with  by  the  presence  of  the  lamp.  Nothing  is  then 
easier  than  to  shde  the  cautery  along  the  tube  whilst  it  is  cold  and  to  approach 
the  polypus  or  granulations.  When  the  point  of  the  burner  has  reached  the 
lesions,  one  turns  on  the  current  and  destroys  the  diseased  surface  completely. 

The  dehcate  point  consists  in  knowing  whether  one  has  burnt  too  much 
or  too  httle.  In  order  to  obtain  the  right  effect,  one  should  proceed  very 
gently  and  slowly,  swab  after  every  apphcation  of  the  cautery,  and  inspect 
the  surface  treated. 

The  cauterization  with  the  electric  cautery  should  be  efficacious  and  not 
dangerous. 

In  order  that  it  should  fulfil  its  purpose,  one  has  to  destroy  the  entire 


358  GONORRHEA 

diseased  area.  One  should  therefore  persevere,  and  apply  the  burner 
again  if  any  pathological  condition  is  left,  and  in  the  case  of  a  polypus  one 
should  make  certain  to  annihilate  its  implantation  basis. 

In  order  to  be  free  from  danger,  the  apphcation  of  the  cautery  should 
not  be  followed  by  any  bleeding.  This  result  is  only  obtained  by  the 
formation  of  a  black  eschar,  and  one  should  aim  at  producing  it. 

If  one  merely  touches  the  surface  of  the  papilloma  with  the  red-hot 
cautery,  immediate  hemorrhage  is  the  rule.  In  order  to  check  it,  the  burner 
should  be  applied  again  to  the  same  spot,  but  without  marked  pressure. 
It  is  essential  not  to  push  the  burner  into  the  substance  of  the  tumour.  This 
practice  would  lead  to  their  becoming  adherent.  Under  the  influence  of 
the  heat,  the  cautery  would  become  firmly  attached,  and  any  attempt  to 
withdraw  it  suddenly  would  be  followed  by  hemorrhage.  A  Hght  touch  is 
thus  essential. 

Operative  and  Post-Operative  Accidents. — The  httle  misadventures  noticed 
in  connection  with  this  method  are  readily  avoidable  if  one  takes  the  neces- 
sary precautions.     One  has  to  consider  the  occurrence  of — 

1.  Smoke. 

2.  Hemorrhage. 

3.  Subsequent  infection. 

1.  Smoke. — When  one  allows  the  electric  current  to  pass  through  the 
platinum  loop  of  the  cautery  after  it  is  apphed  to  the  papilloma,  fumes  and 
smoke  are  invariably  formed.  They  tend  to  obscure  the  field  of  vision  and 
to  render  the  interior  of  the  urethra  too  foggy  to  allow  a  successful  second 
apphcation. 

In  order  to  obviate  this  drawback,  two  measures  are  indicated:  (1)  One 
should  never  burn  any  fragments  of  the  tumour  which  may  adhere  to  the 
loop  inside  the  tube.  The  cautery  should  be  withdrawn  and  the  debris  be 
burnt  in  the  open  air  of  the  room.  (2)  The  fumes  aiid  smoke  within  the 
tube  should  be  allowed  to  escape,  and  this  is  best  done  by  moving  a  mounted 
swab  quickly  to  and  fro  inside  the  urethroscope.  The  fumes  are  driven 
away  in  this  manner,  and  the  visual  field  becomes  clear  again. 

2.  Hemorrhage. — It  is  certain  that  after  every  apphcation  of  the  galvanic 
cautery  a  few  drops  of  blood  come  away  for  a  few  hours  or  days  towards  the 
end  of  micturition.  But,  as  a  rule,  this  bleeding  is  hardly  worth  mentioning, 
providing  one  takes  the  precautions  recommended  above.  When  a  black 
eschar  is  formed  there  is  never  any  serious  hemorrhage.  If,  however,  there 
is  a  httle  more  bleeding  than  one  should  wish  for — ^this  has  happened  to  me 
on  two  occasions — one  can  easily  check  it  by  giving  a  urethro- vesical  irriga- 
tion with  very  hot  boric  lotion,  no  catheter  being  used. 

Amongst  several  hundred  cases  which  I  have  treated  in  this  manner,  I 


THE  TREATMENT  OF  CHRONIC  GONORRHEA     359 

have  never  met  with  any  serious  hemorrhage.     In  one  instance  only  I  found 
it  necessary  to  put  the  patient  into  a  nursing-home  for  twenty- four  hours. 

3.  Secondary  Injection. — In  order  to  obviate  a  secondary  infection  of 
the  urethral  wall,  a  urethro-vesical  irrigation  with  a  1  :  4,000  solution  of 
oxycyanide  of  mercury  can  be  given  with  advantage  immediately  after  the 
cauterization  is  terminated.  These  irrigations  may  be  repeated  on  the 
following  days  if  required.     A  little  urotropin  internally  is  also  often  useful. 

Results. — The  results  yielded  by  intra -urethral  applications  of  the 
electric  cautery  in  chronic  urethritis  are  excellent.  If  one  takes  care  not 
to  intervene  too  often  and  after  too  short  intervals,  and  if  one  gives  the 
urethral  mucous  membrane  at  least  eight  to  ten  days'  rest  between  two 
burnings,  then  one  can  rely  upon  obtaining  brilhant  results. 

When  one  inspects  after  two  to  three  weeks  the  places  with  the  urethro- 
scope which  one  has  burnt,  one  finds  that  all  papillomatous  tissue  has 
disappeared.  Instead  of  the  vegetating  surfaces  present  before  the  treat- 
ment was  instituted,  one  finds  a  white  scar  which  could  not  possibly 
become  the  seat  of  a  recurrence.  The  galvano-caustic  treatment  is  a  sover- 
eign and  supreme  remedy  if  properly  apphed. 

One  should,  however,  be  warned  against  possible  recurrences  of  the 
polypi  which  bud  on  the  verumontanum.  It  is  not  rare  to  find  a  recurrence 
if  one  urethroscopes  several  months  after  one  had  destroyed  a  polypus  on 
the  verumontanum,  and  satisfied  oneself  at  the  time  by  direct  inspection 
of  the  completeness  of  the  operation.  This  finding  seems  to  contradict 
what  we  have  said  so  far,  but  it  only  does  so  apparently. 

It  is  to  be  explained  as  follows : 

On  the  verumontanum  open  the  ejaculatory  ducts,  which  start  in  the 
seminal  vesicles.  If  one  confines  oneseK  to  treating  the  termination  of 
the  sperm  chamiel  only,  without  attending  to  its  origin,  one  obtains  no 
curative  effect.  The  seminal  vesicle  remains  infected,  and  its  pathological 
secretions  continue  to  irritate  the  verumontanum,  which  reacts  always  in 
the  same  way,  as  the  pathogenic  factor  remains  the  same.  Hence  constant 
recurrences  of  the  same  character  result.  It  is  necessary  to  ascertain  the 
soundness  of  the  seminal  vesicles  before  one  treats  papillomata  arising  on 
the  verumontanum.  A  cure  can  only  be  obtained  if  the  seminal  vesicles  are 
free  from  aU  inflammation. 

As  we  have  already  mentioned  in  previous  chapters,  the  relation  of  the 
verumontanum  towards  the  seminal  vesicles  is  absolutely  comparable  to  that 
of  the  ureteric  orifices  towards  the  kidneys.  Ureteric  meatoscopy  enables 
one  to  foresee  and  to  diagnose  renal  lesions,  as  Professor  Hurry  Fenwick 
has  pointed  out.  In  the  same  way  the  aspect  of  the  verumontanum  allows,  us 
to  tell  whether  the  seminal  vesicles  are  in  a  state  of  chronic  inflammation 
or  not.     The  verumontanum  is  the  "  mirror  of  the  seminal  vesicles." 


360  GONORRHEA 

Dr.  Jorge  de  Gouvea,  of  Rio  de  Janeiro,  has  published^  an  interesting 
case  of  sexual  neurasthenia  which,  he  cured  by  means  of  the  galvano-cautery. 

His  patient,  a  mihtary  man  of  forty,  consulted  him  for  the  first  time  on 
July  30,  1910.  He  had  acquired  his  first  attack  of  gonorrhea  eight  years 
previously,  and  had  treated  himself  with  injections  of  silver  nitrate  and  of 
zinc. 

He  had  a  morning  drop  ever  since,  which  he  could  check  by  means  of 
permanganate  irrigations,  but  after  every  excess  a  discharge  supervened. 

When  seen  by  Gouvea,  he  had  to  make  water  very  frequently,  passing 
a  small  quantity  only  on  each  occasion.  Micturition  was  uncomfortable, 
and  a  sensation  of  heat  spread  along  his  perineum  and  his  urethra.  At 
the  end  of  the  act  a  violent  erection  followed.  Pollutions  were  frequent,  and 
during  coitus  the  ejaculations  were  premature  and  painful. 

He  had  lost  a  considerable  amount  of  flesh  lately,  and  was  very  nervous 
and  depressed.  He  complained  of  constant  pains  in  the  loins,  loss  of  appe- 
tite, and  lack  of  interest  in  life. 

The  urine  passed  into  three  glasses  was  clear,  but  contained  filaments. 

After  having  filled  his  bladder  with  a  solution  of  oxycyanide  of  mercury, 
Gouvea  examined  his  urethra.  An  olivary  bougie  No.  12  revealed  the 
presence  of  a  stricture  at  the  end  of  the  penile  portion.  As  the  instrument 
reached  the  posterior  urethra,  the  patient  complained  of  acute  pain. 

Palpation  of  the  kidneys  showed  nothing  abnormal.  Cowper's  glands 
were  also  healthy,  but  there  was  chronic  prostatitis  and  the  seminal  vesicles 
were  tender. 

During  a  fortnight  irrigations  with  permanganate  and  oxycyanide  of 
mercury  were  given. 

The  stricture  was  then  divided  with  KoUmann's  urethrotome.  No  per- 
manent catheter  was  used,  and  after  four  days  dilatation  of  the  anterior 
urethra  with  straight  metal  sounds  was  resorted  to,  until  No.  50  G  was 
reached.  No.  51  G  was  then  tried;  it  passed  along  the  anterior  part  easily, 
but  as  it  reached  the  posterior  urethra  it  gave  rise  to  considerable  pain  and 
to  shght  bleeding. 

A  couple  of  days  later  the  dilatations  were  continued,  preceded  on  each 
occasion  by  an  instillation  of  adrenahn  and  novocain.  Very  slowly  No.  55  G 
was  reached,  and  then  Luys's  urethroscopic  tube  was  passed,  after  the  same 
local  anesthetic  had  been  apphed. 

The  urethroscopic  examination  showed  that  the  condition  of  the  veru- 
montanum  was  the  cause  of  the  malady.  It  was  puffy  and  covered  with  a 
great  number  of  small  raspberry-like  vegetations,  which  were  destroyed  with 
a  fine  cautery  loop.   The  verumontanum  was  painted  with  tincture  of  iodine. 

In  a  week's  time  this  intervention  was  repeated. 

1  Jorge  de  Gouvea,  La  Clinique,  1912. 


THE  TREATMENT  OF  CHRONIC  GONORRHEA     361 

For  a  month  or  so  the  prostate  was  massaged  on  several  occasions,  and 
instillations  of  silver  nitrate  were  given. 

This  therapy  led  to  a  considerable  improvement,  and  after  it  had  been 
continued  for  three  months  the  patient  was  able  to  pass  water  without  any 
difficulty.  All  the  discomfort  complained  of  had  disappeared.  The  ure- 
throscope showed  that  there  were  no  lesions  left.  There  was  no  trace  of  any 
discharge,  and  the  urine  was  normal. 

When  seen  again,  after  six  months,  the  patient  was  perfectly  well. 
A  permanent  cure  had  been  obtained. 

4.  Endoscopic  Surgical  Incisions  of  the  Urethral  Mucous  Membrane.— 
Incision  of  the  urethral  mucous  membrane  is  advisable  in  certain  cases. 
Its  two  chief  indications  are  collections  of  pus  which  one  wishes  to 
empty  through  the  passage,  and  very  hard  fibrous  strictures  which 
fail  to  yield  to  dilatation,  and  which  one  desires  to  divide  under  the 
control  of  the  eye. 

The  intra-urethral  opening  of  a  small  abscess  is  often  of  great  value— 


Fig.    185. — Kollmann's    Small   Knife   for   Intka-Ubethral   Incisions. 

for  instance,  when  there  is  a  tendency  to  spontaneous  bursting  through 
the  skin. 

A  cutaneous  opening  gives  rise  to  a  troublesome  fistula,  which  often 
requires  a  very  long  time  to  heal,  and  therefore  the  endo  -  urethral 
operation  should  be  carried  out  whenever  possible  {vide  Chapters  VIII. 
and  IX.). 

Professor  KoUmann  also  advocates  the  shtting  up  of  inflamed  lacunse 
of  Morgagni  by  means  of  a  special  knife  as  a  curative  measure. 

The  division  of  the  fibrous  portions  of  certain  strictures  which  resist  dilata- 
tion can  be  accomphshed  by  means  of  a  small  cutting  blade  which  one 
passes  into  the  urethroscopic  tube.  As  Menahem  Hodara^  has  pointed  out, 
hard  infiltrations,  running  in  a  longitudinal  direction,  which  do  not  constrict 
the  urethral  lumen,  but  hamper  the  action  of  dilators,  are  sometimes  met 
with.  Internal  or  external  urethrotomy  is  not  suitable  for  these  cases,  as 
there  is  no  narrowing  of  the  urethra.  They  can  be  well  treated  by  means 
of  Oberlander's  urethrotome,  which  enables  one  to  scarify  these  hard  infil- 
trations, guided  by  sight,  in  any  manner  one  may  wish. 

1  Menahem  Hodara,  "  Traitement  de  la  Blennorragie  Chronique,"  Ann.  Oenito- 
Urin.,  August,  1895,  p.  721. 


362 


GONOERHEA 


"  Oberlander's  urethrotome  is  really  ]a  urethroscope  which  carries  a 
groove  on  its  lower  wall,  in  which  a  small  special  knife  can  be  easily  moved 
in  all  directions.  One  examines  the  part  which  one  wishes  to  incise  with 
the  urethroscope,  passes  the  knife,  and  cuts  in  sight  as  desired.     The  little 


Fig.  186. — Oberlander's  Urethrotome. 


knives  are  of  different  shapes;  some  are  triangular,  others  are  very  thin 
and  pointed.  The  former  are  used  for  deep  surgical  incisions,  the  latter 
for  superficial  scarifications."^ 

Oberlander  lays  special  stress  on  this  method.     He  also  recommends  the 


Fig.  187. —  Different  Blades  used  in  Connection  with  Oberlander's 

Urethrotome. 

application  of  a  jfew  electrolytic  punctures  to  these  rebelhous  constricting 
fibrous  patches  in  order  to  bring  |about  [their  jretraction.  At  each  visit  ten 
to  twelve  different  places  can  be  submitted  to  electrolysis.     In  each  instance 


Fig.  188. — Oberlander's  Urethrotome  fully  mounted. 

the  action  of  the  current  diffuses,  and  affects  the  parts  within  |a  circle  of 
0'5  centimetre  radius  around  the  prick  of  the  needle.  In  this  way  all  these 
hard  infiltrations  can  be  destroyed  and  be  made  to  disappear. 

1  Menahem  Hodara,  "Traiteme.it  de  la  Blennorragie  Chronique,"  Ann.  Oenilo- 
Urin.,  September,  1895,  p.  787. 


THE  TREATMENT  OF  CHRONIC  GONORRHEA 


363 


These  interventions  can  also  be  carried  out  by  means  of  certain  special 
instruments — small  curettes — which  are  shown  in  the  figures  below. 


LOUIS.  S:-H.LOEWENST£IN 


Fig.  189. — Small  Sharp  Urethral  Curette. 


UllllS  &  H.LDEWCaSTtJ» 

Pig.  190. — Ordinary  Urethral  Curette. 

The  Treatment  of  Urethral  Stricture  by  Curetting.— Dr.  Paul  Asch,  of 
Strassburg,  has  devised  a  special  method  for  treating  strictures  of  the  urethra, 
which  consists  in  scraping  the  fi.brous  tissue  away  with  a  sharp  curette  under 
the  control  of  the  urethroscope.  ■■■ 


Fig.  191. — Paul  Asch's  Curette  for  Urethral  Strictures. 

He  claims  to  have  obtained  constantly  rapid  and  good  results  with  this 
interesting  process,  which  should  be  reserved  for  those  cases  in  which  the 
cicatricial  tissue  defies  dilatation  treatment.    When  very  tight  strictures 


Fig.  192. — Lohnstein's  Apparatus 

are  present,  he  begins  with  an  internal  urethrotomy.  He  then  practices 
slow  and  methodical  dilatation,  and  if  the  latter  is  found  to  be  inadequate, 
he  removes  the  cicatricial  formations  with  his  curette.  He  thus  prevents  a 
recurrence  of  the  stricture.^ 


Fig.  193. — Terminal  Portion  of  Lohnstein's  Apparatus  for  the 
Posterior  Urethra. 

It  would  seem  as  if  this  method,  which  has  given  Asch  excellent  results, 
were  frequently  indicated. 

Dr.  Lohnstein  of   Berlin   has  also  invented  a  special  urethral  curette. 

1  Paul  Asch,   Urethroskopische  Beitrdge  zur  Diagnose,  Therapie  und  Prognose  des 
Trippers  und  seiner  Folgen,  Berlin,  1907. 

2  Vide  also  Roucayrol,  "  Traitement  des  Retrecissments  de  I'Uretre  par  le  Curetage," 
La  Clinique,  August  9,  1907,  p.  506. 


364  GONORRHEA 

His  instrument  has  two  blades,  which  can  be  placed  in  different  positions 
by  turning  the  terminal  screw  on  the  handle.  It  is  totally  different  from 
Asch's  curette,  and  resembles  in  its  construction  a  dilator.  It  cannot  be 
used  in  conjunction  with  the  urethroscope,  and  is  fitted  with  a  double 
channel  for  continuous  irrigation.  In  certain  cases  its  use  may  be  of  great 
value. 

7.  Instillations  into  the  Urethra. 

The  method  of  urethral  instillations  was  devised  by  Guyon  in  1867,^ 
and  has  as  its  object  the  apphcation  of  a  few  drops  of  a  concentrated  caustic 
solution  to  certain  definite  points  of  the  urethral  mucous  membrane. 

Indications. — Silver  nitrate  instillations  are  certainly  indicated  in  cases 
of  chronic  urethritis  with  locahzed  lesions  in  which  the  exploratory  bougie 
fails  to  reveal  any  induration,  and  in  which  the  urine  is  clear  apart  from  a  few 
filaments  in  the  first  glass. 

This  type  of  condition  is  very  common  towards  the  decHne  of  an  attack 
of  gonorrhea  after  the  gonococci  have  disappeared.  Heavy  filaments  are 
still  found  in  the  first  glass.  They  are  indicative,  as  Verhoogen  of  Brussels 
has  shown,  of  superficial  diffuse  epithehal  lesions  which  are  associated  with 
embryonic  infiltration  and  granulations.  The  latter,  which  have  been 
studied  by  Thierry  and  Desormeaux,  are  the  result  of  the  epithehal  des- 
quamation and  the  exposure  of  the  chorion.  In  cases  of  this  type  a  cure 
can  be  obtained  by  the  action  of  astringents  and  caustics,  and  instillations 
of  silver  nitrate  are  especially  suitable  for  this  purpose. 

There  was  a  time  when  these  instillations  were  fashionable,  and  it  cannot 
be  denied  that  a  great  number  of  patients  derived  considerable  benefit 
from  them.  They  are,  however,  not  free  from  drawbacks,  as  we  have 
already  mentioned. 

The  chief  one  is  the  impossiblity  of  applying  the  medicated  solution 
accurately  and  exclusively  to  the  diseased  surface.  However  skiHul  the 
operator  may  be,  and  however  delicate  his  touch,  the  drops  instilled  into 
the  urethra  spread  forwards  and  backwards,  and  overstep  the  hmits  pro- 
posed. They  are  thus  apt  to  lead  to  disagreeable  effects;  for  instance, 
intense  vesical  tenesmus  and  imperative  desire  to  make  water  are  hkely 
to  supervene  when  one  gives  an  instillation  into  the  posterior  urethra. 
Although  the  silver  nitrate  solution  was  only  destined  for  the  last  portion 
of  the  urethra,  it  inevitably  spreads  to  the  neck  of  the  bladder  and  irritates  it. 

This  untoward  effect  is  impossible  with  urethroscopic  methods  in  which 
the  topics  are  applied  exclusively  to  the  diseased  area  and  cannot  diffuse. 
All  patients  without  exception,  who  have  had  experience  with  both  methods 
of  treatment,  give  preference  to  the  endoscopic  interventions. 

^  Guyon,  Bull.  d.  Soc.  de  Chirurgie,  1867,  2nd  series,  vol.  viii.,  p.  432. 


THE  TEEATMENT  OF  CHEONIC  GONOEEHEA 


365 


Instruments. — The  instruments  required  consist  of  a  drop  syringe, 
holding  4  c.c,  and  an  exploratory  bougie,  which  is  hollow  and  is  perforated 
at  the  tip  of  its  olive. 

The  piston  of  the  syringe  carries  an  arrangement  which  prevents  it  from 
moving  unless  one  turns  the  handle.  In  this  way  the  hquid  is  expelled  drop 
by  drop.  If  one  does  not  make  use  of  this  device,  the  instillation  becomes 
an  injection.  The  silver  nitrate  solution  passes  through  the  bougie,  and 
emerges  at  the  tip  of  the  ohve,  which  is  perforated.  A  single  opening  is 
better  than  a  series  of  Uttle  holes,  because  it  locates  the  fluid  better.  The 
ohve  forms  a  marked  heel  in  order  to  give  the  hand  a  definite  sensation 
when  the  sphincter  is  being  passed. 


Fig.  194. — GuYajs-'s  Syringe  foe  Instillations. 

Technique. — One  fills  the  S}Tinge  with  the  instillation  fluid,  and  affixes 
its  cannula  and  its  bougie.  One  then  presses  on  the  piston  until  the  whole 
instrument  is  filled  with  silver  nitrate  and  free  from  air.  The  movable  screw 
on  t!ie  piston  is  now  fastened.  Every  half-turn  of  the  handle  then  expels  a 
drop  of  the  solution  from  the  tip  of  the  ohve. 

In  order  to  free  the  urethra  from  any  secretions  which  may  be  present 
in  greater  or  less  amount,  the  patient  should  make  water.  Sometim.es  this 
procedure  is  sufficient ;  in  other  cases  it  will  be  advisable  to  give  a  urethro- 
vesical  irrigation  with  a  solution  of  boric  acid  before  instiUin^. 


Fig.  195. — Olivary  Bougie  foe  Instillations  with  Gtjyon"s  Syringe. 


If  one  wishes  to  give  an  instillation  into  both  urethrse,  it  is  necessarv 
to  begin  with  the  posterior.  "  The  ohvary  bougie  is  inserted  at  once  beyond 
the  membranous  portion.  In  order  to  bring  it  into  its  correct  position,  one 
should  withdraw  it  after  it  has  reached  the  posterior  urethra  until  one  feels 
that  the  ohve  rests  on  the  sphincter.  It  is  then  in  its  proper  place.  .  .  .  One 
begins  to  count  the  drops  as  one  turns  the  handle.  Their  number  varies 
according  to  the  indications.  Generally  speaking,  instillations  intended 
for  the  posterior  urethra  should  be  generous  ;  20,  30,  and  sometimes  40  drops 
will  be  required.  A  marked  topic  action  can  only  be  obtained  in  this 
region  if  the  contact  with  the  drug  is  repeated.  .  .  .  The  bougie  is  then 
made  to  lie  in  front  of   the  sphincter,  resting  on  its  muscular  ring.     The 


366  GONOEEHEA 

instrument  is  then  again  in  position.  One  turns  the  handle  again  as  many- 
times  as  necessary.  In  the  region  of  the  bulb  and  in  the  anterior  urethra 
a  smaller  number  of  drops  is  sufficient  to  bring  all  the  parts  into  contact 
with  the  drug. 

"  Even  if  a  very  small  number  of  drops  has  been  instilled  into  the  cul-de- 
sac  of  the  bulb,  one  can  see  the  hquid  oozing  out  of  the  meatus.  Ten  to 
fifteen  drops  are  quite  sufficient  for  an  instillation  into  the  anterior 
urethra  "  (Guy on). ^ 

Silver  nitrate  is  used  for  these  instillations  in  doses  varying  from  1  to 
5  per  cent.  It  is  best  to  begin  with  the  weaker  solutions  until  one  is  ac- 
quainted with  the  susceptibihty  of  the  urethra  one  is  treating.  The  strengths 
used  have  to  be  graduated  according  to  the  reactions  set  up  by  the  various 
instillations. 

We  may  here  mention  an  important  point  to  which  Trekaki  has  drawn 
attention.  An  instillation  with  silver  nitrate  is  only  effective  if  it  produces 
a  reaction  which  is  characterized  by  a  copious  whitish  flow  for  a  few  hours 
after  the  intervention.  One  should  therefore  aim  at  setting  up  this  reaction, 
and  herein  lies  the  art.  One  should  increase  the  strength  of  the  silver 
nitrate  as  required,  but  one  should  not  go  too  far,  and  great  care  must  be 
taken  not  to  set  up  hemorrhage  from  the  urethra.  One  should  keep  within 
the  proper  limits,  which  vary  in  each  case.  If  no  reaction  is  obtained,  it 
is  useless  to  continue;  the  treatment  is  unsuitable  for  the  case  on  which  it 
is  being  tried. 

The  usual  strength  employed,  which  is  free  from  risk  and  yet  effective, 
is  2  per  cent.  It  is  by  no  means  immaterial  if  one  destroys  the  urethral 
epithehum  with  silver  nitrate.  A  well-given  instillation,  which  has  been 
properly  apphed  to  the  diseased  area,  eradicates  the  affected  tissues,  but  it 
can  diffuse  to  the  healthy  parts  and  injure  normal  epithehum.  The  de- 
struction of  the  normal  cyhndrical  epithehum  of  the  urethra  is  aways  a 
calamity,  as  it  fulfils  an  important  role.  It  protects  the  passage  against 
the  ordinary  adventitious  organisms,  and  once  it  is  destroyed  it  is  replaced 
by  flat  cells  of  the  pavement  type,  which  lack  this  defensive  power.  The 
cyhndrical  epithehum  is  never  regenerated  once  it  has  undergone  destruction. 

The  conclusion  to  be  drawn  from  this  is  the  following :  The  more  normal 
and  healthy  epithehum  one  can  preserve  and  save,  the  better.  We  do 
not  hesitate  to  insist  most  especially  upon  the  superiority  of  direct  cauteriza- 
tion with  caustic  under  the  control  of  the  urethroscope.  These  endo-urethral 
interventions,  carried  out  with  a  mounted  stick  of  silver  nitrate,  are  infinitely 
preferable.  They  enable  one  to  destroy  exclusively  the  diseased  areas,  and 
do  no  harm  to  the  healthy  parts. 

1  Guyon,  Legons  Cliniques  sur  les  Maladies  des  Voies  Urinaires,  4th  ed.,  vol.  iii.j 
p.  448;  Paris  (Bailliere),  1903. 


THE  TEEATMENT  OF  CHRONIC  GONORRHEA      367 

Although  silver  nitrate  is  most  generally  used,  other  drugs,  such  as  picric 
acid  and  sulphate  of  copper,  may  be  substituted. 

Dr.  Frank  of  Berlin  has  advocated  instillations  of  copper  sulphate  in 
glycerine.  It  would  appear  as  if  these  solutions  were  more  effective  than 
aqueous  ones  of  the  same  strength. 

8.  On  the  Application  of  Heat  to  the  Urethral  Mucous  Membrane. 

We  have  pointed  out  in  the  third  chapter  (p.  34)  that  the  gonococcus  is 
very  susceptible  to  changes  in  the  temperature,  and  that  temperatures  of 
40°  and  42°  C.  have  a  detrimental  effect  upon  it.  It  dies  within  a  few  hours 
at  this  degree.  Moreover,  chnical  experience  has  shown  that  the  discharge 
ceases  immediately  in  patients  suffering  from  a  gonorrheal  discharge  if 
they  develop  high  fever  (40°  C.  or  more).  It  was  thus  natural  that  one 
should  have  attempted  to  make  use  of  this  observation  therapeutically, 
and  that  one  should  have  considered  it  possible  to  cure  an  attack  of  gonor- 
rhea rapidly  if  one  could  maintain  the  urethra  at  a  temperature  of  42°  C. 


Fig.  196. — Thermo-Electbic  Bougie. 

for  a  number  of  hours.  I  invented  some  thermo-electric  bougies  for  this 
purpose,  which  I  showed  at  the  Association  Fran9aise  d'Urologie  in  1905.^ 

My  bougies  were  made  of  metal  and  hollow  inside.  They  carried  within 
them  a  resistance  by  means  of  which  they  were  heated  as  the  electric  current 
passed  through  them.  A  rheostat  was  interposed  between  the  sound  and 
the  main,  for  graduating  the  current  and  maintaining  the  heat  of  the  bougies 
at  the  exact  temperature.  No  accident  was  possible  with  method,  and 
there  could  be  no  question  of  burning  the  urethra.  I  had  straight  sounds 
made  for  the  anterior  urethra,  and  others  with  a  benique  curve  for  the 
posterior. 

I  apphed  these  thermo-electric  bougies  on  many  occasions,  and  I  regret 
to  have  to  state  that  the  therapeutic  results  obtained  were  far  below  my 
expectations.  The  chief  cause  of  this  failure  appears  to  me  to  be  the 
following:  Although  one  can  heat  the  urethra  in  many  cases  up  to  60°  C. 
without  producing  any  pain,  the  mucous  surfaces  do  not  reach  this  tem- 
perature by  any  means.  If  one  measures  the  temperature  inside  the 
bougie  the  thermometer  indicates  60°,  but  if  one  measures  its  surface  a 
much  lower  temperature  is  recorded.    The  outside  of  the  bougie  is  in  direct 

1  Luys,  C.  R.  de  I'Ass.  Frang.  d'Urol.,  1905,  p.  298. 


368 


GONORRHEA 


contact  with  the  mucous  membrane,  and  through  it  with  the  blood-stream. 
As  the  latter  is  constantly  renewed,  it  constantly  cools  the  parts  and  the 
bougie,  and  lowers  the  temperature.  One  is  thus  confronted  by  two  alter- 
natives: One  has  either  to  increase  the  heat,  in  which  case  the  patient 
immediately  complains  of  pain  and  discomfort ;  or  one  uses 
a  bearable  temperature,  in  which  case  the  heat  produced  is 
not  high  enough  and  the  therapeutic  effect  is  nil. 

In  certain  patients  who  were  exceptionally  resistant  I 
managed  to  experiment  further,  and  I  made  the  interesting 
discovery  that  applications  of  great  heat  for  any  length  of 
time  were  followed  by  profuse  sweating.  In  these  cases 
the  bougie  had  obviously  heated  the  blood,  and  immediately 
the  heat-regulating  apparatus  of  the  body  responded  to 
counteract  the  effect. 

This  treatment,  which  appeared  so  enticing  from  a 
theoretical  point  of  view,  was  thus  of  no  practical  value, 
and  led  me  to  discard  it  altogether. 

The  Application  of  Heat  to  the  Prostate. — In  certain 
inflammatory  conditions  of  the  prostate  a  counter-irritant 
action  on  the  gland  is  of  great  value,  and  the  best  means 
of  carrying  out  this  treatment  appears  to  be  the  application 
of  heat  'per  rectum.  The  problem  to  be  solved  is  how  to 
apply  an  equal  temperature  for  a  considerable  time.  Hot 
rectal  irrigations  have  but  a  temporary  action  of  short 
duration.  As  to  the  other  instruments  which  have  been 
proposed  for  this  purpose,  they  are  either  impractical,  or 
they  are  very  expensive  and  comphcated,  or  they  are 
inconvenient  and  require  constant  attention. 

M.  Colhn  has  made,  according  to  my  instructions,  an 
instrument  which  can  be  manipulated  with  ease.  I  showed 
it  for  the  first  time  at  the  Medical  Congress  in  Madrid  (1903).^ 

The  essential  part  consists  of  a  small  resistance  which 
is  connected  with  the  mains  through  a  rheostat.  It  is 
covered  by  a  metal  disc,  and  is  isolated  in  its  other  parts 
by  means  of  an  insulating  mass.  The  action  of  the  heat 
produced  is  thus  only  manifest  at  the  level  of  the  metal 
disc. 

Before  applying  the  instrument,  one  graduates  the  heat 
to  the  degree  required,  which  one  controls  by  inserting  a  thermometer  into 
the  hollow  of  the  instrument. 

1  Luys,  Fourteenth  International  Congress,  held  in  Madrid,  1903,  Urological  Section, 
p.  127. 


Fig.  197. — Luys's 

"Calefactor" 
for  applying 
Heat  to  the 
Prostate. 


THE  TREATMENT  OF  CHRONIC  GONORRHEA     369 

The  patient  then  lies  down,  and  one  passes  the  "  calefactor  "  into  the 
rectum,  seeing  that  the  metal  disc  is  lying  up  against  the  prostate.  This 
organ  is  heated  as  the  current  passes.  One  regulates  its  intensity  according 
to  the  thermometer,  which  is  left  in  the  instrument. 

In  this  fashion  one  can  obtain  a  constant  temperature  for  an  indefinite 
period.     Its  decongesting  effects  are  remarkable. 

9.  The  Ionization  Treatment  of  the  Urethral  Mucous  Membrane. 

The  localizations  of  chronic  urethritis  which  keep  up  pathological 
secretions  are  deeply  situated  imder  the  mucous  surface,  as  we  have  shown 
in  Chapter  V.  A  method  which  would  allow  one  to  introduce  active  drugs 
deeply  into  the  tissues  would  thus  be  welcome. 

As  it  happens,  nearly  all  therapeutic  agents  which  are  placed  on  the 
urethral  mucous  membrane  fail  to  enter  its  deep  parts,  were  it  only  for 
the  fact  that  they  nearly  all  coagulate  albumin,  and  thus  form  a  kind  of 
varnish  or  armour  which  protects  the  tissues  against  their  action. 

It  would  appear  that  the  experiments  of  Professor  Stephane  Leduc,  of 
Nantes,  were  calculated  to  fill  us  with  fresh  hopes,  and  to  lead  us  to  new 
therapeutic  achievements. 

In  a  series  of  papers  Stephane  Leduc  has  shown  that  the  electric  current 
has  the  property  of  driving  certain  drugs  into  hving  tissue. 

If  one  runs  an  electric  current  through  a  solution  of  a  salt  which  is  a 
good  conductor  of  electricity,  the  latter  is  decomposed  into  an  acid  radical 
which  moves  to  the  positive  pole,  and  a  basic  radical  at  the  negative  pole. 

The  human  body  is,  owing  to  the  sodium  chloride  which  it  contains,  a 
very  good  conductor,  and  thus  it  is  easily  understood  that  it  should  be 
possible  to  drive  some  metal  into  the  tissues  by  using  metal  electrodes 
connected  with  the  positive  pole.^ 

Numerous  essays  of  this  kind  have  already  been  carried  out,  in  gynecology 
especially.  In  1890  Prowodnik  used  a  copper  electrode.  Propyalkowsky 
apphed  zinc  electrodes,  Regnier  iron,  Debedat  aluminium,  and  Boisseau 
du  Rocher  silver. 

I  have  attempted  to  do  to  the  urethral  mucous  membrane  what  had  been 
done  to  the  uterus,  and  I  have  apphed  this  ionization  in  cases  of  chronic 
urethritis  with  success. 

I  have  used  silver  and  zinc,  but  the  former  metal  seemed  to  me  infinitely 
better.  The  reaction  set  up  by  the  zinc  is  very  marked,  and  the  therapeutic 
effect  small ;  in  the  case  of  silver  the  results  were  much  more  satisfactory. 

The  best  technique  to  adopt  is  the  following:    The  urethra  and  the 

1  Vide  Desfosses  and  Martinet,  Presse  Medicate,  No.  1,  1907;   Zimmern,  Rev.  d. 

Gynecol-  et  de  Chirurgie  Abdom.,  No.  3,  October,  1906. 

24 


370  GONOKHHEA 

bladder  are  washed  by  means  of  a  urethro-vesical  irrigation  with,  boric 
lotion,  no  catheter  being  used.  One  then  passes  a  silver  sound  into  the 
urethra,  a  straight  one  for  the  anterior,  and  a  curved  one  for  the  posterior. 
The  end  of  this  sound  is  connected  by  means  of  a  wire  with  the  positive 
pole.  The  negative  one  is  attached  to  a  sheet  of  lead,  surrounded  by 
absorbent  wool,  which  is  placed  on  the  patient's  thigh.  One  then  allows 
the  current  to  pass.  One  graduates  it  by  means  of  an  amparemeter,  and 
works  it  slowly  up  to  10  to  15  milhamperes.  After  a  quarter  of  an  hour 
one  interrupts  the  current.  The  sound  in  the  urethra  will  then  be  found 
to  be  intimately  adherent  to  its  walls,  as  if  it  were  soldered  in.  It  is  im- 
possible to  withdraw  it,  and  any  traction  on  it  merely  gives  rise  to  intense 
pain  and  frightens  the  patient  out  of  his  wits.  There  is  a  very  simple  and 
easy  way  of  freeing  it.  One  has  only  to  reverse  the  current — i.e.,  to  connect 
the  negative  pole  with  the  sound,  and  the  positive  with  the  pad  on  the  thigh, 
and  pass  a  current  of  3  or  4  milliamperes.  After  a  few  minutes  the  benique 
becomes  movable  and  can  be  withdrawn  easily. 

One  notices,  once  it  is  outside  the  urethra,  that  it  is  blackened  wherever 
it  was  in  contact  with  the  mucous  membrane;  the  electric  current  oxidized 
it  and  brought  about  the  formation  of  silver  oxide. 

In  two  cases  suffering  from  rebellious  discharges  which  had  resisted 
far-pushed  dilatation,  I  obtained  a  complete  cure.  In  both  the  lesions 
were  situated  in  the  penile  urethra,  and  two  or  three  apphcations  had  the 
desired  effect.^ 

Dr.  Suquet  of  Nimes^  is  in  favour  of  applying  ionization  as  soon  as  the 
acute  stage  of  gonorrhea  has  passed  ofE.  He  uses  zinc  ions.  Once  the 
glans  and  the  prepuce  have  been  cleansed  and  the  urethra  has  been  washed 
with  a  5  : 1,000  solution  of  zinc  sulphate,  a  zinc  sound  No.  40  G  is  passed. 
The  negative  pole  is  connected  with  the  abdomen,  and  the  wire  of  the 
positive  pole  is  attached  to  the  sound.  One  runs  a  current  of  8  to  10  milh- 
amperes through  the  sound  for  eight  to  ten  minutes.  The  current  is  then 
reversed,  and  one  completes  the  treatment  by  applying  15  milhamperes 
for  five  minutes.  After  a  few  hours  the  discharge  increases  to  a  marked 
degree.  If  the  reaction  is  too  violent.  Dr.  Suquet  resorts  to  high  frequency 
on  the  same  evening  and  on  the  following  days. 

Within  two  to  four  days  after  the  ionization  the  discharge  disappears; 
it,  however,  comes  on  again  if  one  does  not  repeat  the  treatment. 

Four  to  five  applications,  given  once  a  week,  are  required  for  a  cure. 

1  Luys,  "  De  I'lntroduction  par  I'Electricite  de  Substances  Medicamenteuses  dans 
la  Muqueuse  Uretale,"  La  Clinique,  January  25,  1907,  p.  53. 

2  "Traitement  de  la  Blennorragie  et  de  ses  Complications  par  rElectricite,"  JElec 
tricite  Medicate,  December,  1907,  and  Rev.  Prat,  des  Mai.  d.  Organes  Genito-Urin.,  No.  24, 
January  1,  1908,  p.  456. 


THE  TREATMENT  OF  CHRONIC  GONORRHEA      371 


10.  Salves  and  Urethral  Suppositories. 

The  treatment  with  salves  and  urethral  suppositories  is  a  method  which 
is  justifiable  in  certain  cases. 

Janet^  recommends  it  for  chronic  urethritis  of  the  mucous  and  desquam- 
ative type. 

Urethral  Salves. — The  advantage  of  these  salves  lies  in  their  great  pene- 
trating power.  They  enter  the  folds  of  the  mucous  membrane  and  the 
lacunae  fairly  well,  but  they  do  not  reach  the  interior  of  the  mucosa.  The 
fat  which  they  contain  adheres  to  the  surface  of  the  urethra,  and  moulds 
itself  on  its  folds.  These  salves  thus  enter  into  a  more  intimate  contact 
with  the  mucous  discharges  from  the  lacunse. 

Then,  again,  the  fact  that  they  adhere  prolongs  the  action  of  the  anti- 
septic which  they  contain,  and  protects  the  walls  of  the  urethra  against 
the  irritant  action  of  the  urine. 

Tommasoli,  Casper  and  Unna  used  silver  nitrate,  creohn,  and  sulphate 
of  copper,  incorporated  in  a  mixture  of  lanohne  and  olive-oil.  Casper  intro- 
duced these  ointments  into  the  urethra  on  grooved  sounds.  These  grooves 
were  destined  to  prevent  the  bulk  of  the  salve  from  sticking  to  the  meatus. 
Janet  uses  the  same  method  for  applying  an  ointment  which  has  the 
following  composition: 

Lanoline      . .  . .  . .  . .  . .  17-5  grammes. 

Glycerine  . .  . .  . .  ' . .       7-6        ,, 

Sodium  borate  . .  . .  . .  . .       0-5  gramme. 

Zinc  oxide  . .  . .  . .  . .       2-0  grammes. 

To  this  base  he  adds  an  active  substance,  eithsr  2  or  5  per  cent,  protargol, 
or  silver  nitrate  1  to  2  per  cent.,  or  salicylic  acid  1  per  cent. 

He  boils  his  grooved  sound,  waits  till  it  is  cool  and  dry,  and  fills  the 
grooves  on  it  with  the  salve  by  means  of  a  steriHzed  spatula.  The  sound 
is  then  passed  into  the  urethra,  and  left  there  for  two  to  five  minutes . 

Karo^  uses  a  paint  tube  with  a  conical  end,  which  he  calls  "  tubogonal." 
It  contains  the  salve.  Karo  advocates  ointments  containing  2  to  5  per  cent, 
of  protargol  or  albargin. 

The  treatment  is  carried  out  by  the  patient,  who  holds  his  glans  with  the 
left  hand  and  applies  the  end  of  the  tube  to  the  meatus.  As  he  squeezes 
the  latter,  the  salve  enters  the  urethra  and  fills  it.  The  meatus  is  then 
closed  by  pressing  it  together  with  two  fingers,  whilst  the  other  hand  massages 
the  urethra  for  three  minutes  or  so.  This  method  is  very  simple  and  easy. 
The  consistency  of  the  fat  basis  insures  a  prolonged  contact   of  the  active 

1  Janet,  C.  R.  de  VAss.  Franq.  d'Urologie,  1898,  p.  201. 

2  Karo,  Amer.  Journ.  of  Urology,  vol.  vii.,  No.  6,  June,  1912,  p.  2D2. 


372  GONORRHEA 

drug  in  a  more  effectual  manner  than  solutions  would,  and  the  salve  is 
introduced  in  such  a  gentle  way  that  all  complications  involving  the  posterior 
urethra  are  excluded. 

Urethral  Suppositories  (Medicated  Bougies). — Ultzmann  was  one  of  the 
first  to  utiHze  medicated  bougies  in  the  treatment  of  gonorrhea.  They 
consisted  of  small  cylinders,  made  of  cocoa-butter,  in  which  drugs  (alum, 
tannin,  zinc  sulphate,  silver  nitrate,  etc.)  were  incorporated.  These 
medicated  bougies  were  introduced  through  a  hollow  tube  which  was  fitted 
with  a  stilette  ("  Dittel's  ointment-introducer  "). 

Janet  has  also  invented  urethral  suppositories.  His  bougies  have  the 
shape  of  a  thin  pencil,  and  are  rounded  off  at  one  end,  whilst  the  other  one 
is  hollow.     Their  base  consists  of — 

Sodium  borate        . .  . .  . .  . .     0-10  gramme. 

Zinc  oxide  . .  . .  . .  . .     0-30         „ 

Cocoa-butter  . .  . .  . .  . .     3-00  grammes. 

For  six  bougies. 

The  patient  can  be  entrusted  with  these  suppositories  as  long  as  they  are 
inserted  into  the  anterior  urethra  only.  This  is  easily  done  by  pushing 
them  into  the  passage  with  a  stilette.  When  it  is  desired  to  introduce  these 
bougies  into  the  posterior  urethra,  the  medical  man  should  attend  to  their 
insertion. 

An  interesting  method  for  passing  these  suppositories  into  the  urethra 
has  been  contrived  by  Escat  of  Marseilles.^ 

He  uses  a  catheter  with  a  cut-off  end,  to  which  he  affixes  the  medicated 
bougie.  By  passing  the  instrument  into  the  urethra,  he  is  able  to  deposit 
the  bougie  in  any  part  of  the  passage,  even  in  the  prostatic  region. 

11.  Electrolysis  of  the  Urethral  Mucous  Membrane. 

Electrolysis  can  be  resorted  to  with  success  in  certain  cases.  One  is 
occasionally  enabled  to  put  an  end  to  a  rebelhous  urethritis  by  its  use. 
Dr.  Roucayrol^  has  lately  dwelt  upon  the  value  of  this  treatment,  which 
renders  good  service. 

Indications. — Electrolytic  treatment  should  only  be  used  after  a  high 
degree  of  dilatation  has  been  reached.  ■  It  is  most  especially  indicated 
when,  after  dilatation  with  curved  sounds  up  to  No.  60  G,  Kollmann's 
dilator  has  been  apphed  to  the  penile  urethra  up  to  No.  40,  and  no  further 
progress  can  be  made.     One  often  finds  that  the  branches  of  the  instrument 

1  Escat,  C.  R.  de  V Ass.  Frang.  d'Urologie,  1898,  p.  208. 

2  Roucayrol,  "Detersion  Electrolytique  des  Glandes  Urethrales  Malades,"  abstract 
from  Rev.  Prat,  des  Mai.  des  Org.  Genito-Urin.,  September  1,  1910. 


THE  TREATMENT  OF  CHRONIC  GONORRHEA 


373 


will  not  separate  farther  after  this  high  degree  of  dilatation  has  been  reached, 
not  even  if  one  uses  a  certain  amount  of  force.  One  is  then  disarmed,  as 
there  are  'ptill  filaments  in  the  urine,  unless  one  resorts  to  another  method, 
such  as  electrolysis. 

Technique. — The  patient  makes  water  to  begin  with.  One  fills  his 
bladder  with  a  solution  of  boric  acid  by  means  of  a  urethxo-vesical  irriga- 
tion. One  then  takes  an  ordinary  metal  sound,  a  straight  one  if  the  lesions 
are  in  the  penile  urethra,  and  a  curved  one  for  those  of  the  posterior.     One 


Fig.  198.— Discharge  obtained  immediately  after  the  Electrolytic 
Cleansing  :  Desquamated  Epithelial  Cells.     (Roucaj-rol.) 

selects  the  largest  size  which  passed  so  far,  and  inserts  it  into  the  urethra. 
One  then  attaches  to  it  by  means  of  a  pair  of  forceps  a  wire  leading  to  the 
negative  pole  of  the  battery,  and  places  another  electrode  on  the  thigh, 
connecting  it  with  the  positive  pole.  The  current  is  then  passed;  15  to  18 
milliamperes,  according  to  the  size  of  the  sound,  for  four  to  five  minutes 
are  sufficient.  One  then  removes  the  somid,  and  asks  the  patient  to  make 
water  into  several  glasses.  The  boric  lotion  passed  into  the  first  glass  is 
then  found  to  contain  filaments  which  are  similar  to  those  which  he  passed 
before  .he  was  treated. 


374 


GONORRHEA 


It  would  appear  as  if  this  were  a  special  and  selective  action  of  the 
electrolysis  on  the  diseased  parts  of  the  mucous  membrane,  and  that  they 
alone  were  affected  by  the  beneficial  action  of  the  electrolysis. 

At  all  events,  this  therapy  yields  towards  the  last  stage  of  the  treatment 
of  chronic  urethritis  good  results  which  deserve  to  be  pointed  out. 


Fig.  199. — Discharge  obtained  immediately  afteb  the  Electro  lytic 
Cleansiisig.    (Roucayrol.) 

The  nuclei  of  the  cells  are  undergoing  filamentous  degeneration. 


Resume  of  the  General  Line  of  Treatment  in  Chronic  Urethritis. 

Such  is  the  general  plan  of  treatment  which  should  be  adopted  for  curing 
chronic  urethritis. 

The  therapy  of  chronic  urethritis  should  always  be  based  on  the  same 
general  plan.  In  the  beginning,  urethro-vesical  irrigations  diminish  the 
intensity  of  the  inflammation.  As  soon  as  possible  one  combines  them  with 
massage  of  the  glands  connected  with  the  urethra  (prostate,  seminal  vesicles, 
Cowper's  glands).  When  all  acute  inflammatory  symptoms  have  dis- 
appeared, slow,  methodical,  and  far-pushed  dilatation  of  the  urethral  mucous 
membrane  is  indicated.     Once  it  has  reached  a  certain  degree,  urethroscopy 


THE  TREATMENT  OF  CHRONIC  GONORRHEA 


375 


can  be  applied  without  difficulty.  It  enables  one  to  tell  if  there  are  any 
diseased  patches  left  which  require  special  treatment  (dilatation  of  the 
highest  degree).  Once  the  latter  has  done  its  duty,  a  new  urethroscopic 
examination  is  necessary,  and  on  the  findings  which  it  yields  will  depend  the 
choice  of  further  treatment  (intra-urethral  application  of  the  galvanic 
cautery,  electrolysis,  etc.). 

This  therapy  undoubtedly  requires  a  long  time  for  its  application,  but 


Fig.  200. — Discharge  obtained  One  Hour  and  Six  Hours  respectively 
AFTER  THE  Electrdlytic  Gleansing.     (Roucayrol.) 

Marked  leucocytic  reaction. 

this  is  the  only  grievance  which  one  could  have  against  it.     For  one  may 
say  that  it  leads  to  a  certain  and  lasting  cure. 

One  should  famiharize  oneself  with  this  hne  of  conduct  and  follow  it 
rigorously.  One  should  never  allow  oneself  to  deviate  from  it,  not  even  when 
the  patients  protest  against  it,  and  this  is  not  infrequently  the  case.  The 
lamentations  and  complaints  of  the  patients  are  often  bitter  and  eager.  Ricord 
knew  them  well  when  he  said:  "  If  I  should  go  to  hell  some  day,  I  know  what 
I  will  be  in  for.  I  will  be  surrounded  by  people  suffering  from  gonorrhea  who 
worry  me  incessantly  with  their  complaints  and  implore  me  to  cure  them." 


376  GONORKHEA 

On  the  other  hand,  one  should  also  know  when  to  stop  treatment — i.e., 
when  the  oozing  from  the  urethral  mucous  membrane  is  absolutely  clear 
and  when  the  urine  contains  no  longer  any  filaments. 

One  meets  not  infrequently  with  patients,  usually  neurasthenics,  who 
have  acquired  a  mania  of  squeezing  and  mauling  their  penis  incessantly. 
Even  when  there  is  not  the  sHghtest  lesion  in  their  urethra,  they  manage 
to  irritate  the  glands  of  the  passage  to  such  an  extent  that  the  slightest 
contact  produces  a  secretion,  which  may  even  be  pretty  free.  These  people 
constantly  bother  their  medical  man;  they  absolutely  refuse  to  believe  that 
they  are  cured.  They  run  from  one  specialist  to  another,  and  threaten 
always  to  commit  suicide  if  one  does  not  comply  with  their  wishes  and  does 
not  cure  them. 

Certain  American  urologists  have  contrived  an  excellent  method  of 
dealing  with  them.  They  apply  enormous  bhsters  to  the  penis,  which 
produce  a  painful  wound  requiring  a  dressing.  They  thus  prevent  the 
patient  from  mauling  his  organ  and  from  irritating  his  glands  incessantly 
by  squeezing  them. 

This  often  acts  like  magic.  Once  the  wound  caused  by  the  blister  has 
healed,  the  patients  frequently  find  that  all  oozing  has  ceased.  They  are 
enthusiastic,  and  thank  their  surgeon,  whom  they  had  cursed  whilst  the 
blister  was  working  wonders. 

One  should  never  resort  to  one  of  the  methods  mentioned  above  ex- 
clusively, and  rely  on  it  alone.  Very  generally  one  should  combine  several 
of  them,  and  use  them  simultaneously. 

One  seldom  meets  with  a  case  with  only  one  diseased  focus.  As  a  rule, 
the  lesions  of  chronic  urethritis  are  multiple. 

Amongst  the  most  often  employed  combinations  we  may  mention  dila- 
tation and  irrigation,  dilatation  and  injection,  dilatation  with  massage  of 
one  or  several  inflamed  glands. 

One  of  the  most  important  rules  which  Oberlander  has  so  well  pointed 
out,  demands  that  one  should  occasionally  interrupt  all  local  treatment  and 
give  the  patients  a  complete  rest  for  a  time.  Moreover,  one  should  under- 
stand to  use  the  different  methods  alternately.  As  Professor  Oberlander 
rightly  says,  there  are  cases  of  urethritis  which  fail  to  respond  to  irrigations 
and  are  reheved  by  dilatation,  and  there  are  others  which  are  refractory 
to  dilatation  and  improve  with  simple  irrigation  treatment. 

Lastly,  one  should  not  confine  oneself  to  local  therapy.  The  general 
health  of  the  patient  also  deserves  consideration. 


INDEX 

Numbers  in  heavy  type  denote  the  chief  references. 


PAGES 

Abortive  treatment 298 

Abbamowitch 296 

Abscess,  gonorrheal  metastatic  .      .     37,224 
prostatic 195,  196 

ACQUAPENDENTE,  FaBRICIUS  D'        .        .  9 

Adenitis,  inguinal 189 

Adrenalin 156,328 

Aero-urethroscope,  Von  Antal's      .   125,  127 

,,  Fenwick's    .      .      .     128 

,,  Gordon's     .      .      .     133 

Wasserthal's     .   132,  134 

Ahlfeld 230 

Ahlstkom 290,  300 

Albarran 185,  196,  345 

Albuquerque,  Azevedo     ....     135 
Anatomy  of  the  glands  connected  with 

the  urethra 60 

Anatomy  of  the  urethra 48 

Andrews 121 

Angioma 352 

Anglada  1 

Antal,  Von 125,  132 

Apostoli 262 

Arculanus 6 

Aret^us  of  Cappadocia    ....         2 

Argelata,  Peter 5 

Aristotle 2 

Arthralgia,  gonorrheal 220 

Arthritis,  acute  gonorrheal  .      .      .      .221 
AscH,  Paul    .      .      .  136,  201,  202,  273,  363 

AsHARA 33,216 

Aspirator,  intra-urethral      .      .      .      .319 

AuBEPiN,  Henry 18 

AuFuso 33 

AURELIANUS,  CCELIUS 3 

AusPiTZ 127 

avioenna 3 

Baermann 200 

Bakei 10 

Balano-posthitis 94,  187 

Balsam  preparations       .    215,  216,  257,  292 

Balzer 274,  289,  291,  315 

Baraban 67 

Barrier 93 

Barib 248 

Barlow 285 

Barnes 286 

BarthoUn's  glands     .      .     112,  115,  251,  264 


PAGtS 

Baumes 21 

Bayon 14 

Bazet 200 

Beaufumb 36 

Belfield,  William 201,  208 

Bell,  Benjamin 9,  24 

Benario 287 

Benassi 291 

BENiQui: 11,  97,  100,  326 

Bertrand,  Felix 242 

Bettmann 199,  300 

Bezancon 32,92 

BiELK 247 

BlERHOFF 258 

Bier's  method 260,297 

BiLLOIR 4:2 

Birth-rate,  decline  of 16 

Blokusewski 271 

bockhardt 33, 216 

BOGDAN 25 

BOHM 322 

boisseau  du  rocher 369 

Bonnet 249 

bonniere 241 

bosquillon 10 

BOTTINI 179 

BouDiN 291 

Bougies,  exploratory 94 

,,        filiform 333 

for  instillations      ....  365 

,,         medicated 304 

,,        thermo-electric      ....  367 

BOURBAU 303 

Bourdon 249 

BozziNi 121 

Brassavolb 7 

Braun's  svringe 262 

Bru,  Paul 17 

Bruening 124 

Bbun,  De 291 

Brunswick-le-Bihan    ....  233, 234 

Buerger 142 

BuMM 10,  31,  33,  67,  232,  259 

BURCKHARDT 76 

Calefactor,  prostatic 368 

Callari 15 

Campbell 224 

Carageorgiades 227 


377 


378 


GONOERHEA 


PAGES 

Carle 18 

Casper      ....  126,  217,  289,  314,  371 

Cassel 224 

Cassis,  Vidal  de 25,  200 

Castan 289 

Catheter  gauge 94 

Catheterization,  contra-indications      .        94 

„  exploratory      ...        94 

,,  of  ejaculatory  ducts  .     210 

,,  technique  ....        95 

Causation  of  gonorrhea  .      .      .21,  330,  267 

Celsus      2 

Chantembsse 231 

Chauffard 226 

Chatjliac,  Gxjy  de 5 

Chaumier 267 

Chenot 77 

Cherrer 36 

Chetjrlot 170 

Chevallier 274 

Chiaiso 241 

Chopart 293 

Choroiditis 245 

Christmas,  De 31,  33 

CiVIALE 11,  334 

Clado 135 

Clar's  photophore 128 

Collan 198 

COLOMBINI 37, 230 

COMANDON 27 

Complement  fixation 37 

Complications  of  gonorrhea  .      35,  187.  290, 

299, 303 

articular        ....  219 
cardiac    ....     35,226 

cerebral 249 

cutaneous      ....  225 

digestive       ....  229 

nervous 247 

ocular 242 

rectal 232 

respiratory    ....  241 

sexual 191 

urinary 214 

CONDY 283 

Conjunctivitis  in  the  new-born  .      .      .  242 

,,             in  children  and  adults  .  243 

CONSTANTINUS  AfRICANUS    ....  4 

COFILLARD 194 

COURTADE 322 

COURTOIS-SIJFFIT 36 

COURTY 262 

Cowper's  glands   .      .      56,  63,  102, 191,  325 

Cruise 121 

Cruveilhier 57 

Cullerier 21, 273 

Cultivation  of  the  filaments  ....  92 

,,         of  the  gonococcus    ...  31 
,,         of    the    gonococcus    from 

blood 36 

Ctjmantjs,  Marcelltjs 6 

Curetting  of  urethra 363 

,,        of  uterus 263 

CUTTLER 230 


Cystitis,  gonorrheal  .      .      .      . 
Cystoscope,  Luys's  direct  vision 

,,               ,,       for  man  . 

,,               ,,       for  woman    . 

,,                ,,       technique 
Schlaginweit's  . 
Cysto-urethroscope,  Buerger's  , 

Dangers  of  gonorrhea 
Debedat 

PAGES 

.  214, 252 
.   144,  180 
.      .      144 
.      .      180 
.      .     182 
.      .      109 
.      .      142 

12,  35,  226 
.      .     369 

Delacour      

.      .       47 

Delbet,  Paul 

.      .       15 

Delbet,  Pierre 

Delefosse 

15,  203,  262 
.      .     299 

Desnos 345 

Desormeaux        .    10,  13,  121,  124,  326,  364 

Despres 194 

Desvignes 198 

Diabetes 46 

Diagnosis  of  bartholinitis  .  .  .  .  115 
of  cowperitis  ....  102,  192 
oflittritis  ....  91,100,168 
of  posterior  urethritis  .  81,  90 
of  prostatitis  .  104,  173,  195,  196 
of  urethritis  in  women  .  Ill,  180 
of  vesiculitis  .  .  110,  161,  204 
Diaphotoscope,  Schutze's  ....  124 
DiDAY     .     22,   78,   79,  86,  241,  258,   273, 

282,  298 

DiEULAFOY 35,  36 

Dilators,  curved 339 

„       Frank's 339,340 

,,       irrigatmg 336,  340 

,,       Kelly's,  for  meatus  .      .      .      .     328 

,,       KoUmann's  .      .      .       335,  338,  340 

Oberlander's       ....  333,  339 

Dilatation  of  the  urethra     .       172,  174,  185 

adjuvant  methods     .      .      .     343 

general  rules 329 

untoward  results.      .      .   169,342 

value  of 326,  343 

with  curved  sounds   .      .      .     329 
with  special  instruments      .     333 

DiNKLERS 67 

DioNis 9 

Discharge,  examination  of    .      .  85,115,234 

"  Diver's  helmet  " 161,213 

Diverticula  of  meatus     .     50,  93,  114,  253, 

258,  284,  312 

DONNAT 263 

Douglas's  pouch 263 

Dressings,  intra -urethral      ....  303 

,,         permanent 313 

Dreuw 319 

Drugman 248 

Du  Castel 199 

DUCHASTELET 282 

DuFOUR 247 

DUHIL 18 

dumontpallier 262 

Duncan,  Andrew 241 

Eastman 325 

EcouviUonnage 257,  304 


INDEX 


379 


PAGES 

Egina,  Paul  of 3 

Ejaculatory  ducts      .      .      .      .56, 204, 210 

troubles       .       80,  84.  204, 205, 

211,  349 

Electrolyse!-,  Luys's 345 

Electrolysis     ....     262,345,351,372 

,,  circular 345 

,,  cleansing 372 

glandular 351 

Electrolytic  needle,  Kollmann's      .      .      351 

Electroscope,  Casper's 126 

Electro-urethroscope,  Nyrops's .  .  .  124 
Endocarditis,  gonorrheal  ....  226 
Endometritis,  gonorrheal     ....     260 

Engelbreth 299 

Englisch 194 

Epicurus 2 

Epididymitis,  gonorrheal     .      .  84, 198,  277 
,,  medical  treatment  of     .     199 

surgical  treatment  of     .     200 
, ,  vide  also  Orchitis 

Ebaud 195 

Ernst 200 

EscAT 289,  372 

Eschbaum's  notch 26 

Examination  of  Cowper's  glands    .   102,  192 

,,  of  female  urethra      .  Ill,  180 

of  filaments     .      .      .       27,  90 

of  Littre's  glands,  91,  100,  186 

of  prostate      .       104,  173,  195 

,,  of  seminal  vesicles,   110,   161, 

204 

of  the  discharge,  27,  85,  115, 

234 

urethroscopic       .      .      .     148 

Fabry 67 

Faure-Beaulieu 35, 227 

Feleki      .      .       107,208,299,321,322,324 

Fenwick Ill,  126,  135,  359 

Febreol 219 

Ferri,  Alphonso 7 

Filaments,  cultivation  of     ...      .        92 
, ,  examination  in  urine     .      .       90 

,,  staining  of 28 

Finger  .  24,  33,  66,  67,  69,  91,  214,  270,  288 
Finger,  raddish- 220 

FiNKELSTEIN 10 

FoLLEN  Cabot 287,  300 

FoUiculitis 100,  171,  189 

para-urethral      .       186,253,258 
,,  urethroscopic  treatment     .     171 

FoBGUE 351,  352 

Fournier       .     200,219,222,224,241,247, 

250,  273 

Fbaenkel 29 

Fbaisse 136,  163 

Frank       .      11,  107,  135,  271,  272,  339,  367 

Fbendl 228 

Frequency  of  gonorrhea.      .      .     15,21,232 

Frisch,  Von 136,  232 

fuebbringeb 91 

Fuerstenheim 121 

Fuller 208,209,220,222 


Gaddesden,  John  of     . 

Galen       

Galvanic  cautery. 
Gardanus      .... 
Gas,  action  of,  on  urethra 


PAGES 

.      .      .  5 

.      .      .  2 

312,  328,  351 
.  .  .  9 
.      .      .     313 


Geissler,  Von 231 

Gemy 295 

Geraud 242 

GiROD 45 

Glands,  Bartholin's  .      .     112,  115,  251,  264 

,,       Cowper's       .      56,  63,  102,  192,  325 

,,       Littre's    .      44,  58,  61,  72,  91,  100, 

165,  168,  185,  189,  284,  285,  317, 

326  351,  355 

„       prostatic  .'  62,  75,  99,  104,  107,  173, 

175,195,320 

,.       Skene's 258 

,,       Tyson's 

GOLDSCHMIDT 


Gonococcus  .  26,  67,  107,  174,  204,  216,  292 


93,  94,  174,  312 
.      .   140,  173 


25,  35 
21,  24,  230,  267 
.     12,35,226 
iectionsof  vac- 

...  307 
,  13,  80,  174,  246 
.  .  15,21,232 
35,  206, 227,  22S 
,  .  .  .  1 
.   .   .  25,266 


Gonorrhea  and  fever 
causes  of 
dangers  of 
diagnostic  inj 

cines     . 
duration  of 
frequency  of . 
generalized 
history  of 
in  children 
in  the  aged 

in  women  ....  111,250 
latent  .  .  .  .18,  112,  114 
legal  aspect  of  .  .  .  16,18 
local  complications  of    .      .     187 

malignant 36 

pathology  of 66 

prophylaxis  against .  .  4,  270 
serum  and  vaccine  therapy, 

223, 226,  305 
struggle  against.  ...  17 
systemic  complications  of  .     218 

Gordon '^ 

Gordon,  of  Vancouver 133 

GossELiN 112 

GOUEGUES 283 

GouvEA 135,360 

Gbadwohl 37 

Gram's  method 29 

Gravis 42 

Geegoire ''6 

Griffon 32,  92,  223,  232 

Grosse 272 

Grosz 198 

Gruenfeld 126,129,166 

GuAiNER,  Anton 6 

GUELLIOT 323 

GuBRiN,  Alphonse 56,  326 

Guerin's  sinus 56 

Guerin's  valve 56 

GuiARD,    25,  43,  114,  204,  241,  271,  287,  294, 

304 

GuiLLON,  Paul 301 

GuYON       ....    49,  107,  108,  364,  366 


380 


GONORRHEA 


PAGES 

Haab 10 

Hacken 121 

Hagner 201,  216 

Halle 67, 227 

Halliee 10 

Hallion 186 

Hamonic  .      .      .46,  98,  201,  235,  253,  316 

Hakkis 36 

Harbison 47, 94 

Haetmank.  Henri   .      .      13,  166,  194,  232 

Hayem 247 

Heat,  treatment  by 367,  368 

Hegar's  dilators 183,261 

Heiman 32 

Heissler 81 

Heitz-Boyee 122 

Heller 33 

Helmont,  Van 9 

Henry 272 

Hernandez 10 

Hervibux 219 

Hippocrates 1, 4 

History  of  gonorrhea 1 

,,       of  urethroscopy 121 

Hodara,  Menahem  .      .    225,  327,  337,  361 
HoGGE 102,  191,  321 

HONNORA 230 

HoRAND    .      .  230,232 

HoRTELOUP    ....     122,  124,  127,  273 

HoRWiTZ 224 

HUGITET 304 

Hunter,  John 9,  79 

Hydarthrosis,  gonorrheal     .      .      .      .221 
Hygroma,  gonorrheal 223 

Impotence 84, 204 

Infection  by  inert  objects     .      .      24,  25,  51 

,,         paradoxal        .      .      .      .       23.  53 

modes  of     ...      .  21,  230,  231 

Infiltrations,  hard     .      .      .       163,  166,  349 

soft       .      .      .       163,  164,  349 

Injections,  abortive        .  ...     298 

anesthetic     .      .      .      .151, 280 

drawbacks  of        81,  82,  189,  290 

indications  f  or    .      .      .      .     290 

,,  solutions  for 291 

Inoculation  experiments .      .      .      .'       10,33 

Instillations 287,  347,  364 

Ionization  treatment      ....  263,  369 

Irrigations,  permanganate    .      .      .  283,  313 

,,         other  solutions  used      .      .     284 

,,         technique      ....  255, 276 

Jacqxjet 224,  226 

Jadassohn 67,  69,  88,  287 

Jamin 45 

Janet  .  39,  93,  127,  163,  255,  258,  271, 
275,  278,  283,  284,  286,  301,  302, 
303,  312,  314,  318,  327,  349,  351, 
371,  372 

Jaejavey 56 

Jarvis 307 

Jaylb 115,261,262 

Jeanbratj 337,  351 


PAGES 

Jbanselme 226 

Johnson 156 

Johnston 36 

Jullien     .      .      .13,  16,  115,  232,  233,  241 

Jttngano 292 

JURGENS 230,231 

Kamen 288 

Kammer 267 

Karo 371 

Kaitpmann 133,  135 

Keersmaecker,De  .      .        58,75,135,163 

Kelly 183,217,327 

Kerassotis 224 

Kervin 292 

Keyes 324 

Kimball 231 

Klingelhobffer 219 

Klotz 210 

KOCHBB 206 

Koch's  bacillus 45,  192 

KoLLMANN  .  11,  67,  88,  107,  108,  120, 
128,  132,  135,  136,  162,  165,  257, 
330,  334,  337,  344,  349,  351,  355, 
361 

Krohmeyeb 89 

Kuehne's  blue 28 

LABBi,  Marcel 248 

Lacuna     8 

Lacunae  of  Morgagni     .    66,  72,   100,  165, 

168,   185,  284,  285,  326,  349,  351, 

353 

Lallemand 47,  96 

Lanpranc      4 

Lang 125,  224 

Lautier 35 

Lavaux 45 

Lazear 228 

Lebreton 191 

Lecene 194 

Le  Damany    ........     226 

Le  Dentxj 134 

Lbduc,  St^phane 369 

Le  Falher 31 

LeFur     ......       140,196,207 

Legal  aspect  of  gonorrhea    .      .      .       16,  18 

Lbgrain 40,  42 

Lequeu 188,  190,  193, 291 

Leiteb 123,  131 

Leroy 289,291 

Leszynski,  Von 28 

Leucoplakia,  urethral     ....  167,  348 

Levi 291 

Lewin 287,  322 

Lewis,  Bbandseoed 208,216 

LiCHTENBERG 59,  60 

Littre's  glands  44,  58,  61,  72,  91,  100,  165, 
168,  185,  189,  270,  284,  285,  317, 
326,  351,  355 

LoHNSTEiN 89,  287,  363 

LOYSEAU    9 

LuYS     .      57,  100,  109,  129,  136,  144,  180, 
210,  235,  345,  346,  367,  368 


INDEX 


381 


PAGES 

Mainini,  Carlos 306 

MAii:coT 289 

Malherbe 231 

Marcellus  Cumanus 6 

Marianus  Sanotus 6 

Marriage  and  gonorrhea .      .      .     13,14,119 

,,         consent  to 92,  119 

IVIartineau 46, 257 

Massage  instruments,  Dreuw's  .      .      .     319 


Eastman's 
Feleki's    . 
Janet's    . 
Keyes's    . 
Stordeur's 


325 
107 
318 
324 
319 


Massage  of  Cowper's  glands 
,,        of  Littre's  glands  . 
,,         of  prostate  . 
,,         of  seminal  vesicles. 

Massa,  Nicolas  .... 

Masturbation       .... 


102, 192,  325 
.  .  100,317 
104,  196,  320 
.  .  208,322 
22 
.  80,  178,  195 

Mauriac 273 

Maute 307 

Mazza 241 

Meatotomy 328 

Meatus,  urethral  .    50,  92,  114,  183,  312,  327 

Melun 300 

Menahem  Hodara.     Vide  Hodara 

Mendelssohn 216 

Meningococcus  and  gonococcus ...        34 

Mercier 47 

Merlin 291 

Mermet 232 

Metal  sounds 97,  100,  329 

Metritis 259 

Meyer 225 

Michel 37 

Miles 297 

MiNiNE 266 

MONTAGNIN 195 

MORGAGNI 9,  56 

Morgagni's  lacunae.     Vide  Lacunae 

MoscATO 42 

Moses  .      .      .      •      •  L 

Moxz   .      .'      .      .      .      67,72,100,314,315 
Mucous   membrane,   urethral,   anatomy 

of    .      .      .     59,  159 
,,  ,,  urethral,  pathology 

of     66,  162,  323,  342 
,,  ,,  urethral,  action  of 

vapours     .  315,  316 
,,  ,,  urethral,  electrolysis 

of    ....     372 

MURCHISON 216 

Myalgia,  gonorrheal 223 

Myelitis,  gonococcal 247 

Myocarditis,  gonococcal 229 

Neelsen 67 

Neisser 10,21,285 

Neuralgia,  gonorrheal     .    ' .      .      .      .     247 

Neurasthenia 84,  360,  376 

Newman 345 

Nicolaysen 33 

Nicolle 28 


pages 

NiTZE 131 

NoBL 26 

Noeggerath 15 

NoGUES 26.  35,  43 

Nyrops 124 

Oberlander  .  11,67,76,107,108,120, 
127,  131,  136,  162,  167,  326,  330. 
334.  351,  355,  361,  376 

Oraison 190 

Orchitis,  a  bascule 84 

,,         double 203 

,,         gonorrheal 9,  igg 

Otis 125,  163,  167,  326,  344 

Palpation  of  the  urethra lOO 

Paltauf 224 

Pan-electroscope.  Leiter's    ....      123 
Papillomata  and  polypi,  76,  93,  165, 176,  355 

Paraphimosis 3,  igg 

Pare,  Ambroise g 

Parmentier 247 

Pasteau 50 

Pathology  of  gonorrhea  ....  66, 163 

Pechin 242 

Pelletier 76 

Pericarditis,  gonoccocal.      .      .      .      .     229 

Periostitis,  gonococcal 224 

Peritonitis,  gonococcal    .      .       207,  262,  264 
Perivesiculitis,  gonococcal  ....     207 

Peter 219 

Petit 230 

Petrini  Galatz 200 

Pezzer,  De 282 

Pezzoli 287 

Phimosis 187,  268 

Photophore,  Clar's 128 

PiCARD 49 

Picker 207,  233 

Picot 107,  199 

Pinto 34. 

PiROGOFF 200 

Plato 2 

Pleurisy,  gonococcal 36,  241 

POLAILLON 262 

Polyarthritis  deformans       .      .      .      .221 
Polypi  .     76,  93,  176,  177,  178,  241,  254.  355 

PONTOPPIDAN 299 

POPYALOWSKY 263 

PoROSZ.  MoRisz 42,  289 

PORTALIER 174 

POSNER 126 

Pozzi 25,  262,  263 

Prat 267 

Prepuce,  examination  of 94 

Prockoska 227 

Prophylaxis  against  gonorrhea  .      .       4,  270 
,,  in  acute  gonorrhea      .  273,  274 

Propyalkowsky 369 

Prostate,  anatomy  of 62 

,,         endoscopic  treatment       .      .      175. 
,,         examination  of       .       104,  173,  195    • 
,,         inflammation  of,  107.  175.  277,  369 
massage  of  .      .     104,  173,  195.  320 


382 


GONORRHEA 


PAGES 

Prostate,  measuring  of 99 

,,         pathology  of 75 

therapy       .      .     175,  195,  320,  369 

Prostatic  fossette 160,  173 

Prostitutes      .      .      .  113,  230,  231,  233,  250 
Pyelitis  and  pyelonephritis,  gonococcal,  216 

Pabblais 6 

Recipe  for  getting  the  clap  (Ricord's )    .        22 

Peclus 188 

Rectoscope,  Luys's 235 

Rectoscopy .     237 

Rectum,  gonorrheal  lesions  of    .      .     23,  232 

Regnier 369 

Reliquet 65, 204 

Rendu,  A 227 

Retention  of  urine     .      .    218,248,257,267 

Reverdin 283 

Phases 3 

Rheumatism,  gonorrheal      .      .      .      .218 

,,  muscular 223 

Rheuss 272 

Rich 283 

RicoBD      .      10,  13,  22,  25,  47,  270,  290,  293, 

299,  309,  375 

Robert 226 

Roentgen  rays  and  seminal  vesicles      .     209 

Roger 4 

Roger,  Paul 15 

Rogers 305 

Rollet 10,233 

Roquette 293 

rostnsky 67 

Rothschild 142 

RorrcAYROL 1,  273,  363,  372 

Rousseau 41 

ROUTIER 198 

Roux 188 

Rudaux 16 

Sabotage  of  medical  examination   .      .  112 

Sabouraud 314 

Sahli 224 

Saint-Philippe         47 

Salerno,  School  of 4 

Salicet,  Guillaume  de      .      .      .      .  4 

Salmon 272 

Salpingo-ovaritis,  gonorrheal     .      .      .  263 

Santorini's  plexus 65 

Sappey 56 

Sard,  De  .      .      .      .  286,  291,  301,  321,  336 

Savignac 47 

ScHAFFER 33,286,287 

Schaick,  Von 15 

SCHENCK 46 

Schlagenhauser 33 

Schlaginweit 109,  323 

Schmidt 306 

SCHMITT 42 

SCHOLTZ 33 

SCHROEDEB 263 

SCHUTZE 124 

Secretions  in  gonorrhea,  variation  in 

virulence    .      .      .     .  12,  22,  252,  265 


Sedatives  for  erections 275 

Segalas 121 

Second 194,  195 

Sellei 216 

Seminal  vesicles    .       110,  161,  204,  220,  246, 

248, 322,  359 

Seneca     2 

Septicemia,  gonococcal   .      .      .  35,  227,  228 

Serum  reaction 37 

,,      therapy 305 

Sidney 228 

SiGURTA 145 

Silver  salts      .      .  6,  45,  216,  243,  284,  290, 

298, 348, 366 

Simon 65 

Siredy,  De 262 

Skene's  glands 258 

Social  struggle  against  gonorrhea    .      .       17 

SoLiNGEN,  Van 9 

Speculum  for  meatus      ....     93,  114 

Spillmann 283 

Spitzer 272 

Stark 287 

Steckel 272 

Stein 121 

Steinschneider 32 

Sterility 203 

Stern 136 

Stievenabd 42 

Stordeur 272,  318,  319 

Strictures,  rectal 234,  239 

urethral   .      97,98,163,167,253, 
267,  329,  333,  345,  362 

Suarez  de  Mendoza 136 

SUCHARD    . 266 

Supply  of  electricity 145 

Suppositories,  rectal 196 

urethral 257 

,,  vaginal 259 

Suquet 370 

Suspensory  bandage 5,  273 

Susruta    3 

swediaur 10, 21 

Swinburne 286 

Symptoms  of  acute  anterior  urethritis  .       78 
,,  of  acute  posterior  urethritis       82 

, ,  of  chronic  posterior  urethritis     83 

, ,  of  vesiculitis 204 

Synovitis,  gonorrheal 223 

Syphilis  and  gonorrhea,  relationship, 

6,  9,  10,  234 


Tansard  . 
Tapret 
Tazembre 
Technique, 


291, 


Terrier 


micro-biological 
of  direct  vision  cystoscopy 
of  instillations    .... 
of  intra-urethral  therapy    . 
of  irrigations      .      .      .  255, 

of  massage 

of  rectoscopy      .... 
of  urethroscopy 


315 
194 
230 
27 
182 
365 
346 
278 
317 
235 
148 
185 


INDEX 


383 


Testut      .    50,  51,  52,  53,  54,  55,  63,  64,  65 

Thayer 36,228 

Thevenot 37 

Thierry 364 

Thompson 87, 326 

ToLET,  Francois 9 

Tommassoli 371 

tourbt-pialat is 

TOUTON 67 

Toxin,  gonococcal 33,35 

Trajectotome.  Janet's 312 

Treatment,  abortive 298 

antiphlogistic  ....  272 
by  balsams  .  215,216,257,292 
by  dilatation  239,  257,  261,  326 
by  ecouvillonnage  .  .  257,  304 
by  electrolysis    .       262,  345,  372 

by  heat 367 

by  injections  .  .  .  289, 314 
by  instillations  ....  364 
by  ionization  .  .  .  263, 369 
by  irrigations  .  255,  275,  313 
by  vapours  ....  262,316 
resume  of,  in  chronic  ure- 
thritis   374 

urethroscopic     .      .      .  256, 346 

Trekaki 366 

Trendelenburg's  position      ....      184 
Tuberculosis  of  genito-urinary  organs, 

45,  192,  215 

Tuffier 45 

TUTTLE 232 

Tyson's  gland 93,  174 

Ulmann 37,299 

Ultzmann :      •  255,  372 

Unna 314,  371 

Ui'ethral  and  para-urethral  diverticula. 

Vide    Meatus,  Tyson's   gland,  Mor- 

gagni's  lacunae,  etc. 


,,           ,,       lumen  of. 

49 

■±0 

137 

,,       histology 

58 

,,           ,,       pathology     . 

66 

162 

,,     female,  anatomy 

65 

,,           ,,       histology 

66 

„           ,,       pathology     . 

253 

Urethritis,  "  aseptic  "     . 

43 

due  to  adventitious 

orgs 

misms,  39 

,,               ,,      chemicals 

45 

,,               ,,      diathesis  . 

46 

,,               ,,      toxins 

46 

,,      trauma     . 

47 

Urethrograph,  Hamonic's    . 

98 

Urethroscope, Buerger's  . 

142 

Desormeaux's 

122 

,,             for  posterior  urethra 

139 

,,             Goldschmidt's 

140 

,,             Griinf  eld's 

126 

,,             Heitz-Boyer's 

122 

,,             Horteloup's     , 

123 

,,             Kaufmann's    . 

135 

,,             Kollmann's,  for 

pho 

tog- 

raphy     . 

. 

133 

PAGES 

Urethroscope,  KoUmann-Wiehe's    .   128,  130 

,,  Lang's 125 

Le  Fur's 140 

,,  Luys's 136 

Nitze's 131 

Oberlander's         .      .      .      131 

Otis's 125 

,,  Valentine's      .      .      .      .132 

VonAntal's    .      .      .   125,127 

Wossidlo's      ....     143 

Urethroscopic  tubes,  Gruenfeld's     .   126,  129 

Luys's.      .      .   136,  180 

,,  ,,       ordinary   .      .      .      129 

Urethroscopy,  contra-indications    .      .      155 

,,  dangers 119 

,,  history 121 

,.  importance   .      .      .      .      117 

,,  technique      ....      148 

,,  therapeutic  value,  118,349,353 

Urethroscopy  of  anterior  urethra    .   159,  162 

,,  of  posterior  urethra  .   160,  172 

,,  of  female  urethra .      .      .      180 

Urethrotome,  Albarran's  and  Desnos's      345 

,,  Kollmann's     ....      344 

,,  Fessenden  Otis's  .      .      .     344 

Oberlander's         .      .      .     362 

Urethrotomy,  complementary  .      .      .      344 

Urine,  examination  of 86 

,,       filaments  in 86,  90 

phosphates  in 87,205 

Urorrhea 86, 270 

Uteau 289 

Utriculus 55,  178,  212,  349 

Vaccine  therapy  ....       223,  226,  305 

Vadja 206 

Vaginitis,  gonorrheal      ....  242,  258 

Valentine 132,  135 

Valescus  of  Tarentxjm      ....         5 

Valve,  Guerin's 56 

Valves,  accessory  urethral  ....        57 

Van  den  Corput 283 

Vas  deferens 201,207,208 

Vasotomy 201,  208 

Veil 14 

Vbnturi,  Silvio 249 

Verchere       .        14,  113,  233,  250,  257,  259 

Verhoogen    ...      58,  75,  135,  163,  364 

Verumontanum   .       55, 83,  96, 161,  176,  177, 

178,  179,213,355,359 

Vesiculectomy 209 

Vesiculitis       .      204,  220,  246,  248,  322,  359 

Vesiculotomy 209,222 

Vidal 226 

Vidar 249 

ViGNERON 327 

ViGNOLO-LUTATI 291 

Vigo 6 

voelcker 210 

voillemieb. 11,  80 

Vulvitis  in  little  girls 25,  268 

Wassermann       .      .      .      .     31,  34,  37,  228 
Wasserthal 132 


384 


GONORRHEA 


PAGES 

Watson-Cheyne 10 

Weber '     .       55 

Weinreich •   .      .       29 

Weiss 219 

Weitz 37 

Welandek .       28 

Webler .'287 

Webtheim 10,  30,  33,  259 

WiDAL 227 

WiEHE 128,  132 

WiLDBOLZ 206 


PAGIS 

WoLBARST      ....       89,266,267,291 

Wolf 28 

WORMSER 136,  174 

WossiDLO.        11,  42,  136,  143,  162,  216,  286, 

301 
Wright 307,  308 


Young 


Zeissl 272,283 

Zydlowitz 287 


BaillUre,  Tindall  and  Cox,  8,  Henrietta  Street,  Covent  Garden 


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